Release of Information from Doctor

What Triangle location do you and/or your loved one attend?*

450 Broadway, Malden493 Main Street (Prism Program), Malden157 Pleasant Street, MaldenRandolphSalem
Definition of Forms
- Release of Information from Doctor: This document is used to give a doctor approval to release information such as medical protocols, allergy information, and any other medical related information.

Release of Information from Doctor
Client Name
Date of Birth

MonthDayYear
Date
I, First Name Last Name , authorize Triangle, Inc. to obtain and/or release protected information from/to:
Full Name and/or Agency:
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
Select all that apply:

PhoneFaxVerbalMailEmail
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The purpose of this authorization is/are:

Behavior data/ABC data/ISP data/Case Notes/Incident ReportsCase Management/ISP progress/Employment supportsAllergy Protocols/Emergency Circumstances
I understand that this release is valid only for the period of one year from the date of my signature and that I may withdraw myconsent at any time. The information to be released has been explained to me and I have had the opportunity to ask questions. I givemy consent voluntarily, without the threat of punishment or promise of reward. I have discussed this release with the person obtainingmy consent and have had my questions fully answered. I understand that I may withdraw my consent at any time without fear ofpunishment.
Parent/Guardian Signature:

Clear
Date of signature

MonthDayYear
Date
Client/Individual Signature:

Clear
Date

MonthDayYear
Date
Signature of person obtaining consent

Clear
Date of signature

MonthDayYear
Date

Save, Preview, and Submit
Please enter an email address here if you'd like to receive confirmation that this form was submitted successfully and a copy of this form.
example@example.com
Should be Empty: