135 Webster St. Suite 1 Hanover, MA 02339 P. 781-429-7755 x1 F. 781-465-7995 E. firstname.lastname@example.org
Authorization for Release of Information
We require all information to be completed and accurate
Client Name (print)
Date of Birth
I hereby a
a Behavioral Health
Please choose one
To provide ongoing treatment/aftercare
Purpose of Request:
Specific Records/Report (s) to be released:
Please check the appropriate information to be released
History and Physical
Drug and Alcohol Records
I understand this authorization does not expire unless a written request is submitted to revoke authorization.
Disclosure(s) made prior to receipt of revocation are authorized under the prior authorization.
I understand that the confidentiality of my records is protected under Federal Regulations (42CRF, Part 2
I understand that I may be charged for any case consultation that will occur between the listed provider above
and my provider.
I have read carefully and understand the above statements and do herein expressly and voluntarily consent to
disclosure of the above information and/or medical records to these persons/agencies named above.
Signature of Client or Legal Guardian
Relationship to Client
Should be Empty: