Authorization to Disclose and Release Protected Health Information Client Name* First Last Client Date Of Birth* MM slash DD slash YYYY Client's Email Address* Relationship to Client*SelfGuardianNature of Guardianship*ParentPower of AttorneyThe requested information is to be released by/to and/or mutually shared with:*NamePhone Number Add RemoveYou may enter more than one by clicking the +How would you like to receive the records?*EmailFaxEmail* 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. Upon submitting this form, you will redirected to a signature page. 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 DateIf a different expiration date for release of records is desired, please enter the date here: MM slash DD slash YYYY