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 InformationPatient Name First Last Patient Date of Birth MM DD YYYY Information to be Disclosed to:I, the undersigned, hereby authorize Lifespan Behavioral Health Services PCto release copies of medical records to:to obtain copies of my medical records from:to speak with regarding my medical recordName of Person/OrganizationAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFaxReason for DisclosureFurther Medical Care/SpecialistInsuranceAttorneyDisabilitySchoolPersonal UseInformation to be DisclosedCheck appropriate boxes Only information related to Please specify Only the period of events from Please specify beginning and ending dates Other Please specify (billing, scheduling, etc.) Entire record If you would NOT like any of the following sensitive information disclosed, check the applicable choices below:Alcohol/Drug Abuse Treatment/ReferralHIV/AIDS-related TreatmentSexually Transmitted DiseasesMental Health (other than Psychotherapy Notes)Psychotherapy Notes ONLY (by selecting this box, I am waiving any psychotherapist-patient privilege)SignatureThis 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.Printed Name* First Last Signature of Patient (if 18 years or older) or Parent/Guardian*Date* MM DD YYYY Relationship to Patient*Forwading Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If applicable