Authorization to Release Information

Complete all required fields (*) and sign below

Client Information

Client Name *

Date of Birth *

Parent/Guardian (if client is a minor)

Phone

Release To / Receive From

Organization or Person *

Address

Phone

Purpose & Information

Purpose of Disclosure *

Information to Share

Diagnosis Treatment Summary Attendance Records Recommendations Advocacy Letter Evaluation Report Other

Direction

→ SEND

Release information to the organization above

← RECEIVE

Receive information from the organization above

Authorization Period

Today's Date

Expiration Date *

Signature

I authorize the use or disclosure of my protected health information as described above. I understand that I may revoke this authorization at any time by written notice, except to the extent that action has already been taken based on this authorization.

Signature *

Sign above using your mouse or finger

Print Name *

Send completed form to:

HIPAA Notice: This form complies with the Health Insurance Portability and Accountability Act. Your protected health information will only be disclosed as authorized above. For questions, contact Dr. Bustamante at the number above.