Authorization for Use or Disclosure of Protected Health Information

First Name

Last Name

Address

Home Phone

Cell Phone

I do hereby authorize named person/facility to release a copy of my mental health information to the person or facility below.

Send

Receive

or upon the happening of the following event:

information

My entire health record Only those pertaining to (Specific provider name and/or dates of treatment) *ENTER BELOW* Authorization for Psychotherapy Notes ONLY (Important: If this authorization is for Psychotherapy Notes, you must not use it as an authorization for any other type of protected health information.) Other *ENTER BELOW*

From Above

Purpose of information release

Purpose

From Above

I authorize the release of my confidential protected health infomlation, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, & the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be re-disclosed by the recipient unless the recipient is covered by state laws that limit the use &/or disclosure of my confidential protected health information.

If signed by a representative:

Indicate your relationship to the client and/or reason and legal authority for signing::

Patient is:

Minor Incompetent Disabled Deceased

Legal authority:

Parent Legal guardian Representative of deceased