Release of Information Form

Release of Information Form

Download the PDF version with the above link or use the form below to submit online

Online Form Submission




I give permission to disclosemy health and mental health care information between:








AND





INFORMATION TO BE DISCLOSED(includes verbal exchange)










Purpose of Disclosure




Expiration Date

Revocation

I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken based on this authorization.

Authorization

  1. I authorize the above facility to disclose information as noted above.
  2. I understand it is possible that sensitive information such as alcohol and drug usagemay be released.
  3. I understand that once the information is disclosed, it may be subject to re-disclosure by the recipient and may no longer be protected.
  4. I understand that this authorization is voluntary and I may refuse to sign.
  5. I also understand that unless allowed by law, my refusal to sign will not affect my ability toobtain treatment, receive payment, or eligibility for benefits.
  6. I understand that the exchange of information may include electronic transmissions.