Authorization to Release

Authorization to Use and/or Disclose Protected Health Information
Patient First Name:
Patient Last Name:
I hereby authorize Laya Seghi, LCSW to release/request information from my records to this person or organization:
Name / Organization:
The information will be used/disclosed for the following purposes:
I understand that this Authorization will be valid and in effect unless it is revoked by me in writing or until it automatically expires 30 days after termination of treatment. If I choose to revoke this authorization, it will prevent any release of information after the date it is received, but can not change any actions taken before that date.

I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment. I also understand that I may inspect and have a copy of any written health information that is shared.

If the person or entity that receives the information is not a healthcare provider or health plan covered by federal privacy regulations, the information described above may be redisclosed and no longer protected by those regulations.
eSignature*
Date*

YearMonthDay
Date
Time*

Hour Minutes
Should be Empty:

Authorization to Use and/or Disclose Protected Health Information