1250 SE Maynard Road, Ste. 204
Cary, NC 27511


Ph: 919-371-4378
Fax 919-300-7943

www.slteletherapy.com

Release of Information for use or Disclosure of Protected Health Information
​​​​1) Client's Name and Address 
First Name: 
Middle Name:
Last Name:
Current Address: 
Phone: 
2) Date of Birth:
3) Authorization initiated by: Name (Client, Provider or Other)
4) Information to be released:

Purpose of Disclosure:  The reason I am authorizing release is coordination of care among involved parties.
5) Person(s) Authorized to make the disclosure:  ​​​​​
6) Person(s) Authorized to receive and make the disclosure:




7) Authorization will expire on
or upon the happening of the following event:

Authorization and Signature:
I authorize the release of my confidential protected health information, as described in my directions above.  I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and 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 and/or disclosure of my confidential protected health information.

Signature Instructions:
Touch Screen: use finger or stylus to sign
Desktop Monitor: use mouse or touchpad to sign

Therapist Name and Signature:

Date: