Personal Growth

Better Quality of Life

Reduced Stress

Authorization for release of confidential information (Primary Care Physician/Psychiatrist)

  • Date Format: MM slash DD slash YYYY
  • I request and authorize _______________ to release and receive my personal healthcare information between:

  • I understand the consent can be revoked at any time, except to the extent that disclosure made in good faith has already occurred in compliance of this consent. If revocation is not received, authorization will be considered valid for a period of one year from date the ROI was attained.

    The facility, its employees, officers, and attending physician are released from legal responsibility or liability for the release of the above information to the extent indicated and authorized.

    I understand that the information released could contain reference to Substance Abuse, Psychological, and/or Psychiatric Impairment.

    To the party receiving this information: this information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. FOR PATIENT RECORDS APPLICABLE UNDER FEDERAL LAW 42 CFS PART 2.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Our mutual client/patient has authorized us to be in communication to coordinate their care. Their Diagnostic Assessment was on ________ and they will follow up with weekly/bi-weekly appointments and/or were referred to _______
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY