Small Business Answers

Release of Information Form

This template can be used to coordinate the release of confidential information during a client's transition of care or other cicrumstances where private records need to be shared.



Authorization for Release of Information
[COMPANY NAME]
[Mailing Address]
[City], [State] [Zip Code]


___________________________________
Name of Client

___________________________________
Date of Birth

___________________________________
Social Security Number

I understand that [State] law requires each client's consent for the release of confidential information related to mental health or developmental disability. With this understanding, I hereby waive any right to confidentiality arising under [State] law and authorize the release of records of information, but only the extent specified below.

I authorize [Company] to release and/or receive the following information concerning myself or my child:

_____ Diagnostic Evaluation Results

_____ Educational Records

_____ Progress Notes

_____ Treatment Plan

_____ Treatment Summary

_____ Discharge Reports

_____ Any and All Records

_____ Other _____________

The above information is only to be released to, and/or from, the following party:


____________________________
Name and/or Agency

____________________________
Address, City, State, Zip Code


This information is to be used for the purpose of _______________________________.

This authorization shall remain in effect until ________________ at which time it shall expire and no further release of information shall be made under its terms. I understand that I can revoke this authorization at any time by giving written notice to the parties named above. I also understand that I have the right to examine and copy the information disclosed.

I herby release the parties named above from any liabilities for release of this information.

____________________________
Signature of Client

____________________________
Date

____________________________
Signature of Witness

____________________________
Date



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