Spencer Psychology

Authorization to Release Information

Client Name:
Client Date of Birth:   

I authorize the exchange of healthcare information between Spencer Psychology and:
Note: Only one name per release. You can fill out multiple releases if needed. Exchange with:  

Relationship to Client:

Information to be Exchanged (Please check choice or write in details for “other”):

Purpose of Release:


This release does not authorize subsequent disclosure by its recipients. Authorization is valid for one year, unless otherwise instructed. I understand consent can be revoked by me at any time in writing, except to the extent that action has been taken in reliance on it by agents of Spencer Psychology.  If substance abuse treatment records are released, they will be accompanied by the following statement:
“This information has been disclosed to you from records protected by Federal Confidentiality Rules (42 C.F.R. part 2.). The Federal rules prohibit you from making any further disclosure of this information unless the further disclosure is expressly permitted by the written consent of the person to whom it pertains or otherwise permitted by 42 C.F.R. part 2. A general authorization for release of medical records or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse present.” The covered entity may not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs the authorization when the prohibition on conditioning of authorizations under 45 CFR 164.508(4) applies.


Electronic Signature of Client/Parent/Guardian:  

Note: If client is 18 or over, client must sign this consent. A parent cannot sign on behalf of a child if the child is 18 or older.