Authorization For Disclosure Of Protected Health Information

  • If patient is 18 years or older, form must be completed & signed by patient. If patient is under 18 years of age, form must be completed & signed by parent/guardian.

  • Patient Information

  • Information to be Disclosed to:

  • Information to be Disclosed

    Check appropriate boxes
  • Signature

  • This authorization will expire within 1 year from the date of signature. I understand that I may revoke this authorization by submitting written notice of revocation to Lifespan Behavioral Health Services PC.

  • If applicable