Authorization for Release of Information Form

  • I (client) hereby authorize use or disclosure of protected health information about me as described below.
  • The information to be released will be used for the psychotherapeutic treatment of the client(s) in a manner that is consistently with all ethical and legal guidelines.

    I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.

    I may revoke or withdraw this authorization by notifying my therapist in writing of my desire to revoke it. However, I understand that any action already taken in advance of this authorization cannot be reversed, and my revocation will not affect those actions. I understand that the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.
  • This field is for validation purposes and should be left unchanged.