Clinical Release of Records Request

Request to View or Copy SARC Records

INSTRUCTIONS: To request access to inspect and/or copy your records, complete this form, sign, date and submit.

Name*

Date of Birth

Date

Program

ClinicalSafehouse

I am asking for the following type of access to my records:

Inspection of my records onlyCopy of my records onlyInspection and Coping of my records

I am asking for the following records to be copied:

All recordsTreatment Plan (s)Other

Specified time period for this request:

From

Month/Day/Year

To

Month/Day/Year

By signing below I acknowledge that I am aware of the confidential nature of the information being disclosed, and understand the benefits and/or disadvantage of disclosing such information. I hereby release the Sexual Assault/Spouse Abuse Resource Center, Inc. (SARC) from all legal liabilities that may result from the release of this information according to this request. I understand that once in possession of my records, my choice to re-disclose this information to others may nullify confidentiality protection offered by federal and state laws/regulations.

**Please note that we will be reaching out to the last confirmed phone number of client to ensure validity of documents request.

Signature*

Date*

Date