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

Disclosure Details

Purpose of Disclosure *

Information to Share/Receive

Direction of Information

SEND (Release To) RECEIVE (Obtain From)

Authorization Period

Today's Date

Expiration Date *

Signature

By signing below, I authorize the release of the information 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.