Authorization of Disclosure Form

AUTHORIZATION FOR USE OR DISCLOSURE OF

PROTECTED HEALTH INFORMATION

First Name

Middle Initial

Last Name

Date of Birth

Date authorization initiated

Authorization inititiated by

Authorization for Psychotherapy Notes ONLY (Important: If this authorization is for Psychotherapy Notes, you must not use it as an authorization for any other type of protected health information.)

Other (describe information in detail):

Purpose of Disclosure: The reason I am authorizing release is:

My request

Other (describe):

Person(s) Authorized to Make the Disclosure:

Person(s) Authorized to Receive the Disclosure:

This Authorization will expire on

or upon the happening of the following event:

Authorization and Signature: I authorize the release of my confidential protected health information, as

described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be redisclosed by the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected health information.

Signature of the Patient:

Signature of Personal Representative

Relationship to Patient if Personal Representative:

Date of Signature

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