Release of Information Form

Release of Information Form

Provide your details and authorize what information can be released, for what purpose, and for how long.
Client Information
Client Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorization
I, the undersigned, hereby authorize:
Organization Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Release/Exchange Information With
To release and/or exchange information with:
Name/Organization
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Purpose of Disclosure
Purpose of Disclosure

Other
If Other, please specify
Type of Information to be Disclosed
Type of Information to be Disclosed

Other
If Other, specify
Signatures
Client Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature
Relationship to Client
Witness or Staff Signature
Should be Empty: