Release of Information – Counseling Resource Services

Authorization to Release Information:

If you would like your therapist to speak to another therapist, medical doctor, family member, or another individual regarding your care, please complete the following form:

Please fill the Authorization to Release Information here. *All dates in Patient Information section refer to date of birth.

Patient Information

I. Authorization

I authorize the following named individual or organization:

Authorized Person/Organization

to release, discuss, or disclose the following:

Select information to be released

Option 2 or 3 – include information here

for the purpose of:

Select purpose

For "Other" – include information here

II. Disclosure

I authorize this information to be shared with:

Receiving Person/Organization

Patient Information

III. Explanation

This authorization is valid until:

Select expiration option

Option 2 or 3 – include information here

IV. Statement of Rights

• I understand that I have the right to revoke this authorization in writing to the authorized person or organization at any time, except where uses or disclosures have already been made based upon my original permission.

• I understand that discussions and disclosures already made based upon my original permission cannot be taken back.

• I understand I may not be able to revoke this authorization if the purpose was to obtain insurance.

• I understand that it is possible that information disclosed under the terms of the authorization may be re-disclosed by a recipient and no longer protected by HIPAA privacy standards.

• I understand that treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether the individual signs the authorization.

• I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

Signature Authorization

Patient Name

Today's Date

Checking this box is the same as your signature

Representative Signature

Representative Name

Checking this box is the same as your signature

Authority to act on behalf of patient

Parent of MinorGuardianOther

Minor Individual Name (If Applicable)

Today's Date

Checking this box is the same as your signature