Authorization to Release Information

Client Name:
Please enter client/child name

Client Date of Birth:  Please enter 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:  
Address:
Phone/Fax:

Relationship to Client:

Healthcare Provider

Family Member/Partner

Other

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

All mental health information

Other

Purpose of Release:

Coordination of Care with others involved in my treatment

Legal Proceeding

Other

 

This release does not authorize subsequent disclosure by its recipients. Authorization is valid for the duration of the study, 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.

 

I have read and fully understand the above statements as they apply to me. I voluntarily authorize this release. A faxed copy of this release is to be considered the same as the original.

 

Electronic Signature of Client/Parent/Guardian: Please enter your full name

Date: