Authorization For The Release Of Information
Please sign the statement below giving your permission for me to communicate with the following individual or agency on your behalf:
_____________________________________________________________
(Name of individual, agency, company to be contacted)
_____________________________________________________________
(Address, city, state, zip of said individual, agency, company)
____________________________________________________________
(Phone/fax)
I, _______________________, born on _____________, hereby authorize
(Name of patient) (birth date)
Jennifer Santos, M.F.T to disclose/obtain (circle one or both) the following information from clinical records:
␣Diagnosis and dates of treatment ␣Summary of treatment
␣Psychological evaluation/assessment ␣Relevant treatment records
␣Other: Phone conversations regarding myself/my child, _____________________________________________________________
(Child’ s full name)
For the following purpose: Coordination of Care.
This authorization and request to disclose or obtain information from my records will expire after one (1) year from the date on which it was signed. I agree that a photocopy of this release form is acceptable. I understand that I have the right to receive a copy of this authorization upon my request.
Patient/Guardian Name ___________________________________________
Patient/Guardian Signature ______________________________________Date _______________
Relationship to patient: ␣Self ␣Parent of a minor
**Please note that all parties who have been present in the office, over the age of 11, must sign the release.
_____________________________________________________________
(Name of individual, agency, company to be contacted)
_____________________________________________________________
(Address, city, state, zip of said individual, agency, company)
____________________________________________________________
(Phone/fax)
I, _______________________, born on _____________, hereby authorize
(Name of patient) (birth date)
Jennifer Santos, M.F.T to disclose/obtain (circle one or both) the following information from clinical records:
␣Diagnosis and dates of treatment ␣Summary of treatment
␣Psychological evaluation/assessment ␣Relevant treatment records
␣Other: Phone conversations regarding myself/my child, _____________________________________________________________
(Child’ s full name)
For the following purpose: Coordination of Care.
This authorization and request to disclose or obtain information from my records will expire after one (1) year from the date on which it was signed. I agree that a photocopy of this release form is acceptable. I understand that I have the right to receive a copy of this authorization upon my request.
Patient/Guardian Name ___________________________________________
Patient/Guardian Signature ______________________________________Date _______________
Relationship to patient: ␣Self ␣Parent of a minor
**Please note that all parties who have been present in the office, over the age of 11, must sign the release.
