AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

1. Client's Name *

2. Date of Birth *

3. Date authorization initiated *

4. Authorization Initiated by (Name: client, provider, or other) *

5. Information to be released *

Authorization is for Psychotherapy Notes ONLY (Important: If this authorization is for Psychotherapy Notes, you must not use it as an authorization for any other type of protected health information.)Other (describe information in detail):

6. Purpose of Disclosure: The reason I am authorizing release is *

My requestOther (describe):

7. Person(s) Authorized to Make the Disclosure *

8. Person(s) Authorized to Receive the Disclosure *

9. This 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 above. I understand that this authorization is voluntary. I can refuse to sign this authorization. I understand that I may revoke this authorization at any time by notifying the custodian of the record in writing. I further understand that such revocation will not apply to information released by the custodian of records in response to this authorization given prior to my request to revoke. I understand that the revocation must be in writing and needs 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 of the Patient *

DATE *

Signature of Personal Representative
(if applicable)

DATE

Relationship to Patient if Personal Representative

By submitting this form, you acknowledge that you have read and understood the Authorization for Use or Disclosure of Protected Health Information form, and you agree to its terms.