Release of Information - Top Psych Doc

Release of Information Form

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

Patient Name*

Date Of Birth

Address

Street Address City State ZIP

Telephone Number*

You,

, may use or disclose the following health care information (check all that apply):*

All health care information in my medical record

Health care information in my medical record for the date(s)

Other (e.g., psychological test data, letters or reports), please specify exactly what information

Please Specify Exactly What Information

For Date(s)

Through

You May Use or Disclose Health Care Information Regarding Testing, Diagnosis, and Treatment for (Circle All That Apply):

Psychiatric Disorders/Mental Health

Drug and/or Alcohol Use

You May Disclose This Health Care Information to: (Complete a Separate Form for Each Party, if More Than One)

Name (or Title) and Organization:

Address:

Street Address City State ZIP

Phone:

Fax:

Reason(s) for This Authorization:

At My Request

Other(Specify)

Other*

This Authorization Ends On:

Or When the Following Event Occurs:

Signature of Patient or Legally Authorized Individual*

Date*

Printed Name, if Signed on Behalf of the Patient(parent, legal guardian, personal representative)

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