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:

Authorization for Progress Notes ONLY

History and Physical

Discharge Summary

Testing Results

Assessment

Ongoing two-way communication

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:

Primary Care Provider
Primary Care Provider Contact Information

Yes No

Psychiatrist:Psychiatrist Contact Information

Yes No

Facility Contact:Facility Contact Information:

Yes No

Therapist Contact:Therapist Contact Information:

Yes No

Family Member(s):
Family Members Contact Info

Yes No

Financial Contact:
Financial Contact Information:

Yes No

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

Type Client Name:

Client's Signature:

Guardian/Power of Attorney Signature