Authorization for Disclosure of Information

Authorization for Disclosure of Information – Mental Health Records

Please complete this form to authorize the disclosure of mental health information from El Consultorio PLLC. Please read carefully and ensure all data is correct before signing.
14901 E Hampden Ave. Suite 390. Aurora, CO 80014

Phone: 720-260-4115

Fax: 720-836-6394

info@el-consultorio.com

www.el-consultorio.com
Patient Information
Patient's Full Name*

NombreApellido
Patient's Date of Birth*

MesDíaAño
Fecha
Name of Parent, Guardian, or Legal Tutor (if applicable)

NombreApellido
SelfFatherMotherLegal GuardianOther
Contact Information of Patient or Guardian
Phone Number*
Favor ingrese un número de teléfono válido.Format: (000) 000-0000.
Email*
ejemplo@ejemplo.com
Address*

Dirección de la calle

Dirección de la calle Línea 2
CiudadEstado / ProvinciaCódigo Postal / Zip
Information Recipient Details

This section allows you to indicate who is authorized to receive and/or share your information. Please provide the name and contact details of any individual or organization with whom you give permission for information to be shared or from whom information may be received.
Recipient's Name*
Organization/Institution
Recipient's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Recipient's Email
example@example.com
Recipient's Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Complete mental health recordProgress notesDiagnosisTreatment planOtro (especifique)
Ongoing medical careInsuranceEducationLegalOtro
Authorization Start Date*

MesDíaAño
Date
Authorization Expiration Date*

MesDíaAño
Date
Additional Comments or Instructions
Consent and Acknowledgments
Signature of Patient or Legal Guardian*

Clear
Date of Signature*

MesDíaAño
Fecha
Should be Empty:

Authorization for Disclosure of Information – Mental Health Records

Patient Information

Contact Information of Patient or Guardian

Information Recipient Details

Consent and Acknowledgments