Client's Name: *

First Name

Last Name

Date of Birth: *

MM

DD

YYYY

Date authorization initiated: *

MM

DD

YYYY

Information to be released: *

Authorization 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

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

My request

Other

Person(s) Authorized to Make the Disclosure: *

First Name

Last Name

Person(s) Authorized to Receive the Disclosure: *

First Name

Last Name

This Authorization will expire on the date below, or upon the happening of the following event: *

MM

DD

YYYY

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. *

I authorize

I do not authorize

Date finished the form: *

MM

DD

YYYY