Authorization For Release of Confidential Information (English)

Authorization For Release of Confidential Information
Yes (16 years of age or older)No (15 years of age or younger)
Client Name*

Last NameFirst Name
Client Email*
example@example.com
Parent or Guardian Name*

Last NameFirst Name
Parent or Guardian Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
YesNo
I hereby authorize Families First Counseling and Psychiatry to RELEASE and/or OBTAIN information TO and/or FROM for the Purpose of:
Agency / Person Name
Contact Person

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Please release/obtain the following information from my Medical, Education, or Medical Health records. NOTE: Specific information must have a check beside information released.
Treatment PlansProgress ReportsHealth/Medical Records (Lab, etc.)Medical InformationEducation ReportsDischarge SummariesPsychological/Psychiatric EvaluationSocial/Development HistoryVerbal CommunicationBio-psychosocial HistoryHIV-Related InformationAlcohol and/or Drug InformationOther
Treatment PlansProgress ReportsHealth/Medical Records (Lab, etc.)Medical InformationEducation ReportsDischarge SummariesPsychological/Psychiatric EvaluationSocial/Development HistoryVerbal CommunicationBio-psychosocial HistoryHIV-Related InformationAlcohol and/or Drug InformationOther
I understand that Families First Counseling and Psychiatry LLC are not contingent upon my decision to permit the release of this information and I have consented freely, voluntarily, and without coercion, and that the above information is accurate to the best of my knowledge. I understand that I have the right to revoke this authorization at any time to the extent that action has already been taken to comply with it. Information will NOT be disclosed to any other party without written consent of the parent or legal guardian. This release is protected under state and Federal Confidentiality Regulations (4s, CPR Part 2 and FS 90.503). A copy is valid in lieu of the original. This consent will expire twelve months after the date signed. I understand that this does not affect information released prior to this date. This document can be revoked at any time with the written consent of the client and/or guardian.
Signature of Patient/Parent/Guardian*

Clear
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