Authorization to Release Confidential Information

AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION
I,   First Name   Last Name   , authorize the following

Person / Agency / Group;

Name/Organization    ATTN:
Street Address    City   State   Zip
Area Code   Phone Number
To disclose information and records regarding my treatment, medical and/or behavioral health condition to the following professional

Person/Agency, Physician and/or Facility;

First Name   Last Name
Street Address    City   State   Zip
Area Code   Phone Number
Information to be released or exchanged include (check all that apply):
Intake QuestionnaireTreatment Plan(s)Treatment Progress SummaryDischarge SummaryReferralsInsurance/BillingOther
The authorized purpose(s) for this release are:
Diagnosis/TreatmentCoordination of CareOther
EMERGENCY CONTACT*
Name / Relationship / Phone
CONSENT REVOKED
Initial / Date
I understand that my health and behavioral health records are protected from disclosure under Federal and/or State law. I may revoke this authorization at any time. This authorization is valid until I revoke it in writing or 6 months after I have completed treatment, whichever is sooner. Once I revoke this authorization, no information can be released except as authorized or allowed by law. File copy is considered equivalent to the original.

This authorization was explained to me as I signed it of my own free will on:
The day day ofmonth 20 year
Client Signature

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Witness Signature

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AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION

I, First Name Last Name , authorize the following

Person / Agency / Group;

To disclose information and records regarding my treatment, medical and/or behavioral health condition to the following professional

Person/Agency, Physician and/or Facility;

The authorized purpose(s) for this release are: