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.

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 Date

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