Authorization For Release Of Information

Client's Name

Date of Birth

Information to be released:

Summary of Treatment to date

Report of Treatment to date

Other

If other, please specify

Purpose of disclosure

Coordination of care

Other

If other, please specify

Persons authorized to make disclosure

Person authorized to receive disclosure

Purpose of disclosure

Written

If written, please specify

Verbal

If verbal, please specify

Electronic

If electronic, please specify

Today's date

Authorization to expire on

I understand that my health information is protected by law. I authorize the release of my confidential health information as indicated above. I understand that my consent is voluntary and I can revoke this permission at any time, except to the extent that it has already been shared based on this authorization. Should I choose to revoke this authorization I will state this in writing.

Signature of Patient

Date

Signature of Personal Representative

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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