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

Patient Name

First Last

Patient Date of Birth

MM

DD

YYYY

Information to be Disclosed to:

I, the undersigned, hereby authorize Lifespan Behavioral Health Services PC

to release copies of medical records to:
to obtain copies of my medical records from:
to speak with regarding my medical record

Name of Person/Organization

Address

Street Address Address Line 2 City State ZIP Code

Phone

Fax

Reason for Disclosure

Information to be Disclosed

Check 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/Referral
HIV/AIDS-related Treatment
Sexually Transmitted Diseases
Mental Health (other than Psychotherapy Notes)
Psychotherapy Notes ONLY (by selecting this box, I am waiving any psychotherapist-patient privilege)

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.

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 State ZIP Code

If applicable