Release of Information Form

Release of Information Form
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I hereby authorize Michelle Watson to access the following medical, psychiatric, or
psychological information from the records of:
Name of Patient/Client

First NameLast Name
Name of Facility/Individual/Agency
Address of Facility/Individual/Agency

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone of Facility/Individual/Agency:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address of Facility/Individual/Agency:
example@example.com
The following information:
For the purpose of:
I hereby consent to the release of the above medical information which may include alcohol, drug abuse, and mental health records obtained in the course of my diagnosis and treatment. It may also include any testing results documenting AIDS, ARC, and any other opportunistic diseases. I understand that authorization serves to give consent to all information in my documenting AIDS, ARC, and any other opportunistic diseases.

This authorization is valid for one year from the date of signing, unless revoked earlier in writing.
Signature
Relationship (Self/Parent/Guardian/Legal Representation)
Witness

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
*Records obtained as authorized by the Consent for Information Release will be maintained in accordance with Federal confidentiality regulations (Title 42 of the Federal Register) which prohibits redisclosure.
Should be Empty: