Client’s Name:DOB:Information to be released : Summary of treatment to date Report Other:Purpose of Disclosure Coordination of Care Other:Persons authorized to make Disclosure:Person authorized to receive Disclosure:Written :Verbal:Electronic:Today’s date:Authorization to expire on:I understand that my health information is protected by law. I authorize the release of my confidential health information as indicated above. I understand that my consent is voluntary and I can revoke this permission at any time, except to the extent that it has already been shared based on this authorization. Should I choose to revoke this authorization I will state this in writing.Signature of Patient:Date:Signature of Personal Representative:(Required) Terms And Conditions
