Authorization to Disclose and Release Protected Health Information

"*" indicates required fields

Client Name*

First Last

Client Date Of Birth*

Client's Email Address*

Relationship to Client*

Nature of Guardianship*

The requested information is to be released by/to and/or mutually shared with:*

Name

Phone Number

You may enter more than one by clicking the +

How would you like to receive the records?*

Email*

Fax Number*

Records to be released are:*

Copies of treatment records

Letter or report produced by therapist

Verbal: Have MCO verbally dialogue with an outside entity or individual regarding treatment.

This is a two part form. After clicking “Submit” below, you will be redirected to another page. Please scroll to the bottom of that page where you will need to electronically sign and then click “Accept and Sign” in order to ensure successful completion of your request.

Unless otherwise specified, this release shall remain in effect for one year from the date of submission of this form.

Requests for copies of records, letters, reports, or verbal consultation may be subject to fees.

Authorization Expiration Date

If a different expiration date for release of records is desired, please enter the date here:

ATD (Authorization to Disclose)

The authorization to disclose in the written consent we need as healthcare providers to discuss details of or release any information related to a client’s work with us.