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
