Authorization for Release or Exchange of Confidential Information

I hereby authorize the following provider to release or exchange confidential information pertaining to my medical, psychological, and/or psychiatric history. This information is being requested for the purpose of completing patient assessment and treatment.

Provider Name: ______________________________________

Address: ____________________________________________

City: ____________________ State: ______________ Zip: ____________

Phone #: __________________

I understand that I may revoke this consent at any time by informing the above parties in writing. However, my revocation will not be effective to the extent that action has been taken in reliance on the authorization.

I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPPA Privacy Rule.

____________________________ __________________________

Name of Patient Signature of Patient

____________________________ __________________________

Signature of Parent/Guardian Date

____________________________ __________________________

Witness Date

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