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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