Health Records Release Form

First Name

Last Name

Date of Birth:

Social Security Number:

Address

Address Line 1

City

State

Zip Code

Country

Phone Number:

Email:

The following provider may disclose or receive the information:

Name of Recipient (First, Last):

Insituation/Organization:

Address

Address Line 1

City

State

Zip Code

Country

Phone Number:

Fax Number:

The following information will be released:

Appointment attendance

Developmental and/or social history

Educational records

Medical history and evaluation(s)

Mental health evaluations

Lab results reviewed with patient

Progress notes, and treatment or closing summary

Other:

The above information will be used for the following purposes:

Case review

Determining eligibility for benefits program

Updating files

Continuing appropriate treatment or program

Planning appropriate treatment or program

Personal use

Other:

The Protected Health Information (PHI) may be disclosed to or sent from the following authorized individual:

Healthcare Provider

Parent

Legal Guardian

School Counselor/Teacher

Other:

Authorized Individual's Name (First, Last):

Phone Number:

Address

Address Line 1

City

State

Zip Code

Country

I understand that this information may be protected by Title 42 (Code of Federal Rules of privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules. I understand that this authorization is voluntary, and I may revoke this consent at any time by providing a written notice, and after (some states vary, usually one year) this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization. If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.

This authorization expires on the date selected. If no date is selected authorization will expire upon termination of services.

Please confirm your identity:

I am the Patient

I am the Parent of the Patient

I am the Legal Guardian of the Patient

I am the Personal Representative of the Patient

First Name

Last Name