Release of Information Form

Authorization to Use or Disclose Health Information
Use this form to authorize Shrink Savannah to obtain, disclose, or exchange the health information you select. Complete every applicable field. This authorization is voluntary.
Patient information
Patient legal name

First NameLast Name
Parent/Guardian if patient is under 18

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone:
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Direction of the Authorization
Person or organization authorized to send or receive information
Name or Organization:
Attention/Department:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Fax:
Secure email
example@example.com
Purpose
Purpose of disclosure

Other
Information authorized
Select the information that may be used or disclosed:

Other
Dates of records
Records dated From:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Through:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sensitive information
The selections below apply only when the requested records contain the listed information. Initial each category you specifically authorize.
Initials: Mental health treatment information
Initials: Substance use disorder records if applicable
Initials: Psychological or ADHD information and test results
Initials: Genetic testing information
Expiration
Expiration Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your rights and important information
- I may revoke this authorization at any time by giving Shrink Savannah a written request mailed to 1601 Abercorn Street, Savannah, GA 31401 or via secure email to info@shrinksavannah.com. Revocation will not affect information already used or disclosed in reliance on this authorization.
- Shrink Savannah generally may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization.
- Information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by HIPAA. Additional federal or state protections may still apply.
- Part 2 records disclosed for treatment, payment, or health care operations may be redisclosed as HIPAA permits, but generally may not be used in proceedings against me without specific consent or a court order.
- I have the right to receive a copy of this signed authorization.
Authorization and signature
I have read and understand this form. I authorize the use or disclosure of the information selected above for the stated purpose.
Patient name
Patient signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Personal representative or parent/guardian name:
Personal representative or parent/guardian signature:
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Should be Empty:

Authorization to Use or Disclose Health Information

Patient information

Person or organization authorized to send or receive information

Purpose

Information authorized

Dates of records

Sensitive information

Expiration

Your rights and important information

Authorization and signature