Release of Information

Authorization for the Release of Information
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
The patient listed above, or their guardian authorized Serenity Bay Health to exchange, receive and disclose information with the following entity (person or agency):
Agency or Name*
Phone Number*
Please enter a valid phone number.
Street Address*
City*
ZIP*
State*
Agency Fax
Please enter a valid phone number.
Agency Email
example@example.com
The following information may be shared or exchanged:*

AssessmentNursing or medical informationDiagnosisDischarge informationPsychological EvaluationContinuing care planMedication Review NotesTreatment plan; progrress in treatmentAppointment Dates and TtimesDemographic informationSubstance use and/or treatmentOther
Additional release options

I authorize the release of all information options listed above, excluding psychotherapy notes (See below option)Psychotherapy notes - (Cannot be combined with any other disclosure, notes are sensitive in nature and it is advised to discuss with your therapist prior to signing. A signature will not guarantee release nor will records be released in certain situations unless compelled.)
Please select a reason for needing these records:*

Coordinate Care with Another ProviderLegal Reasons (e.g., court, disability)Personal Use/ My RecordsInsurance PurposesOther
I understand that:
1. I can cancel this permission at any time. I must cancel in writing and send or deliver cancellation to releasing facility or practice named above. Any cancellation will apply only to information not release by facility or practice.
2. This ia full release including the information detailed above
3. Once my health information is release, the recipient may disclose or share information with others and my information may no longer be protected by federal and state privacy protections.
4. Refusing to sign this form will not prevent my ability to get treatment, payment, enrollment in health plan, or eligibility for benefits.
I have read, understand and agree with the terms listed for the Authorization for the Release of Confidential Information. This release will expire one year from the date listed below unless otherwise specified here:
First Name*
Last Name*
Signature*

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Date*

MonthDayYear
Date
Guardian or Patient*

I am the patientI am the parent or guardian of this patient (Parent/Guardian, if minor or person signing on patient's behalf)
Should be Empty:

Authorization for the Release of Information