Intake Department
135 Webster St. Suite 1 Hanover, MA 02339 P. 781-429-7755 x1 F. 781-465-7995 E. intakes@danabehavioralhealth.org
Authorization for Release of Information
We require all information to be completed and accurate
Patient Information
Client Name (print)
*
Date of Birth
*
/
Month
/
Day
Year
Date
Client Phone:
*
Client Email
*
example@example.com
I hereby a
utho
rize Dan
a Behavioral Health
to:
Please choose one
*
Obtain From
Disclose to
Exchange Information
Provider Name/Facility/Person
*
Street Address
*
City
*
State
*
Zip
*
Phone Number
*
Fax
Please check the appropriate information to be released
*
Intake/Admission Note
Psychiatric Eval
Psychoeducational Testing
Progress Notes
Psychological Testing
Educational Record
Treatment Plans
History and Physical
Police Report
Laboratory Data
Drug and Alcohol Records
Discharge/Closing Summary
Other
To provide ongoing treatment/aftercare
*
Purpose of Request:
Other
Specific Records/Report (s) to be released:
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
*
Date
*
/
Month
/
Day
Year
Date
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