RESZ01 Authorization for Release of Confidential Information

Authorization for Release of Confidential Information

This form, when completed and signed by you, authorizes me to release and receive protected health information from your clinical record with the person or people you designate.

Client Information
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Parent of Minor Child

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Authorization for Release. I hereby authorized the exchange of information between the following parties:

Responsive Centers
7501 College Blvd, Suite 250
Overland Park, KS 66210
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Specific Authorization. I specifically authorize the release and/or exchange of the following confidential information:

All recordsTherapy recordsReportsCorrespondenceTest resultsClinical observationsBilling informationOther (Please specify)
For the following reasons:

At the request of the individualTreatment planningCoordination of careChange of therapist/educatorForensic evaluationOther (Please specify)
Re-disclosure. This release does NOT authorize re-disclosure of confidential information beyond the limits of this consent except in the case of court ordered evaluations where the information may be disclosed to the court. The recipient of this information is PROHIBITED from using the information other than the stated purpose, and from disclosing to any other party without further authorization.

Validity. I understand that this authorization will automatically expire one year from the date of my signature. I may revoke this authorization by sending a written notice to the person or entity authorized to make the disclosure described above.

I authorize the release of information as indicated above.
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature by client or parent/guardian*

Clear
If authorization is signed by a personal representative of the patient, a description of such representative’s authority to act for the patient must be provided. (Parent of minor child, legal guardian, etc.)
Should be Empty: