Release of Information (HIPAA)

This form authorizes the release of protected health information in accordance with HIPAA regulations.

Client Information

Client Name

Date of Birth

Phone

Authorization

Release Information From

Release Information To

Purpose of Disclosure

Information to Release

Treatment Records

Billing Records

Assessment Summaries

Medication Records

Psychotherapy Notes

Other

Expiration of Authorization

Authorization Expiration Date

You may revoke this authorization at any time in writing except to the extent action has already been taken.

Electronic Signature

Client / Legal Representative Name

Signature Date