Authorization to Release Information

Authorization to Release Information

This form authorizes the release of specific information between Carolyn Cole, Psy.D., LLC, and the designated person or organization. It ensures that information is shared only for authorized purposes, such as coordination of treatment, assessment, or at your request. Please review carefully, as signing indicates your consent to the terms outlined, including the duration and scope of the authorization.
Patient Name*
Date of Birth*

MonthDayYear
Date
Information for Release
By checking this box, I hereby authorize Carolyn Cole, Psy.D, LLC to release the following information to an external person or organization listed below.

I authorize the release of the following information
Information to be released by Carolyn Cole, Psy.D, LLC:
By checking this box, I hereby authorize an external person or organization listed below to release the following information to Carolyn Cole, Psy.D, LLC.

I authorize the release of the following information.
Information to be released to Carolyn Cole, Psy.D, LLC:
Person or Organization to Receive/Release Information
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Fax
I am requesting that this information be released for the following reason(s):*

Coordination of TreatmentInformation for AssessmentAt my requestOther
This authorization shall remain in effect until:*

Evaluation and/or treatment are completeThis date (as specified below)Other
This date

MonthDayYear
Date
I understand that I have the right to cancel this authorization by sending written notification to Carolyn Cole, Psy.D, LLC and/or the party named above. However, I understand my cancellation will not be effective to the extent that Carolyn Cole, Psy.D, LLC has already taken action regarding the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that the recipient of this information may re-disclose it and that the information will no longer be protected by the HIPAA Privacy Rule. I understand that my psychologist generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party.
Signature of Client or Guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Authorization to Release Information

Information for Release

Person or Organization to Receive/Release Information