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Authorization To Release/exchange Confidential Information
Authorization To Release/exchange Confidential Information
I
authorize the Counseling Center to:
release to:
obtain from:
exchange with:
the following information pertaining to myself:
treatment summary
history/intake
diagnosis
psychological test results
psychiatric evaluation/medication history
dates of treatment attendance
MM slash DD slash YYYY
other (specify)
for the purpose of:
evaluation/assessment and/or coordinating treatment efforts
other (specify)
This consent will automatically expire one (1) year after the date of my signature as it appears below. I understand I have the right to refuse to sign this form, and that I may revoke my consent at any time (except to the extent that the information has already been released).
Signature of Patiet
(Required)
Date
MM slash DD slash YYYY
Date of Birth
MM slash DD slash YYYY
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Make An Appointment
