ROI

Authorization for Release of Paient Information

Patient/Client Name *

DOB *

Date

Parent/Guardian *

Phone *

Address

Street Address Line 2

State

Zip

I, the undersigned, authorize Stonebridge Alliance, LLC (dba Stonebridge Behavioral Health, P.A.) to provide copies to and/or exchange information with: *

Please release any and all information, both verbal and written, necessary for continuity of care-and/or treatment of the patient named above. Disclosure of the information to be released is for the following purposes

Continuity of Care and/or treatment Other

Describe other

In addition to the general authorization to release information; I authorize the release of records containing an HIV, HIV- related illnesses, AIDS, AIDS-related, or any communicable disease-related information that may be mentioned in any records released. *

Yes, No,

This authorization is valid for: *

One time only Six months not more than one year from today.

I may revoke this authorization at any time by providing written notice of revocation. I acknowledge, however, that I may not revoke the authorization retroactively for information already released. This information is part of a confidential record which is protected by state law. State law prohibits further disclosure of this information without the specific written consent of the protected person, or legal representative, or otherwise permitted by law. TAC-Title 225 Part II-CH 403, subchapter K-403.295

"The use of scanned or facsimile signatures for the execution of this Release shall be legal and binding and shall have the same full force and effect as if originally signed."

PATIENT/CLIENT SIGNATURE (Adult client only)

Clear

DATE

Date

PARENT/GUARDIAN SIGNATURE

Clear

Relationship to Minor

DATE

Date