Release of Information

Release of Information

Authorization to Use and Disclose Confidential Protected Health Information
Patient's Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date
Your relationship to the patient:
Patient's age
What information would you like to be disclosed to the receiving party?

Other
If you selected other, please indicate what you would like to be disclosed?
Purpose for Disclosure

Other
If you selected other, please indicate what you would like to be disclosed?
I authorize Collin Testing and Psychological Services PLLC to:
Person or Organization with Whom Information can be Shared

Please indicate the following person or organization you would like Collin Testing and Psychological Services PLLC to disclose to, exchange with, or receive protected health information from.
Person's Name with Whom Information can be shared:
Organization or Person's Relationship to Patient (e.g., brother)
Person or Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person or Organization Phone
Please enter a valid phone number.Format: (000) 000-0000.
Person or Organization Email Address
example@example.com
Person or Organization Fax #
Please enter a valid phone number.Format: (000) 000-0000.
Terms of Authorization
This authorization is good for a period of 1 year at the time this form is signed.

By signing this document, I understand that I can revoke this authorization at any time prior to that date by contacting the practice in writing. I also understand that if the practice has already shared the information authorized here at the time I revoke this authorization, then it is too late to prevent that information from being shared. I also understand that the practice cannot make completion of this authorization a condition for any treatments or benefits I am entitled to, unless this authorization is necessary to determine eligibility for treatment or benefits or to pay for treatments I receive.
By signing below, I certify that I have read the above document, agree to all the terms, and authorize the release of PHI to the designated recipient(s) for the purposes stated.
Your name:

First NameLast Name
NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.
PLEASE HAVE THE CLIENT FILL OUT THIS FORM.

Individuals 18 and older are legally recognized as adults and must sign their own Release of Information. By law, parents cannot sign for an adult child unless official, court-appointed Legal Guardianship or Power of Attorney documentation is provided.
Should be Empty:

Release of Information

Person or Organization with Whom Information can be Shared