Name *

First Name

Last Name

Client Date of Birth *

MM

DD

YYYY

Recipient Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Recipient Phone# *

(###)

###

####

For the purpose of: *

At my Request

For Coordination of Care

I request that my health information regarding my medical care and treatment be:

Released to

Obtained from

I authorize and request the disclosure of all protected medical information including the following: *

Psychiatric Records

Discharge Summary

Treatment Plans

Psychological Records

Consultation Notes

Alcohol and Drug Tx

Inpatient Hospital Records

Lab Reports and Radiology Reports

Medication List(s)

I understand that: *

I understand that signing this authorization is voluntary and that treatment or payment for treatment cannot be conditioned on the signing of this authorization

I understand the information disclosed under this authorization might be re-disclosed by the recipient.

I have the right to revoke this authorization at any time.

Date *

MM

DD

YYYY