Authorization for Use or Disclosure
of Protected Health Information

Please fill out the following form in order to participate in our activity.

Client Information

Client Last Name

Client First Name

Middle Initial

Date of Birth

Address

Phone

Recipient Information

I, client named on this form, herby authorize to release a copy of my mental health information to the person or facility outlined below. (Please make sure to include the Name, Facility and Phone Number.)

Name, Facility and Phone Number

Date of Authorization

Date my authorization will expire or Description of Event that will cause my authorization to expire.

Information to be Released

Note: Requests for release of psychotherapy notes cannot be combined with any other type of request.

Please choose an option Required

My entire mental health records

Only those portions pertaining to (please detail in the field below)

Authorization for psychotherapy notes ONLY. (Important: If this is authorization for psychotherapy notes, you must note use it as authorization for any other type of protected health information.)

Other (please detail in the field below)

Further details for release of psychotherapy notes

Purpose of Information Release

Options: Further Mental Health Care, At the Request of the Individual, Other. (If other please specify)

Please choose an option Required

Further mental health care

At the request of individual

Other (please detail in the field below)

Further details for information release

Authorization & 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.

sign here

Today's date

If Signed by a Personal Representative

Full Name

Please indicate your relationship to the client and/or legal authority for signing

Thanks for submitting!