Consent for Release of Information

Consent for Release of Information

Please be sure to fill out the entire form and press the "Submit" button at the end
I,   Your Name   , hereby authorize Pitts and Associates, Inc,   Agency or Individual   (   Address and/or Phone Number   ) to release to each other: Any medical, psychological or educational information (in hard copy or electronic format) regarding or relating to the treatment of:   Client's Name

This consent may be ended at any time by the client but ending the consent will not cancel any action that has already been taken as allowed by this form. Unless the client wishes to cancel this consent at an earlier time, it will automatically stop upon the date and/or event and/or condition indicated below:
a.   Date
b.   Event/Condition
It is understood that the duration of this consent will not be longer than would be necessary and reasonable to carry out the purpose for which it is given.
Date signed

MonthDayYear
Date
Signature of Client

Clear
Date signed

MonthDayYear
Date
Signature of Client

Clear
Date signed

MonthDayYear
Date
Signature of Client

Clear
Note to party receiving information: This information has been disclosed to you from records whose confidentiality is protected by federal law prohibits you from making any further disclosure of information without the specific written consent of the person to whom it pertains, and as otherwise permitted by the regulations A general authorization for release of medical and other information is not sufficient for this purpose.
Should be Empty: