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Release of Information – Staff Requested – GForm
Release of Information - Staff Requested
Use this form to request that your client or their parent/guardian sign a release of information.
Today's Date
*
Date Format: MM slash DD slash YYYY
Are you sending this release to the client or the parent/guardian of a minor child?
*
Client
Parent/Guardian
Client Name:
*
First
Last
Client's Date of Birth
*
Month
1
2
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12
Day
1
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Year
2022
2021
2020
2019
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2012
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1927
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1925
1924
1923
1922
1921
1920
Name of the individual who will sign this form:
*
This may be the client, or the parent/guardian.
First
Last
Email of Person Signing Form:
*
This may be the client or the parent/guardian. A signed copy of this authorization will be sent to this email.
Agency/Person for whom the release is being signed
Are you signing a release for a personal contact like a significant other, or a business/agency? *
Personal Contact
Business/Agency
Agency Name:
Required if "business/agency" is selected above.
Contact Person's Name:
Required if "personal contact" is selected above.
First
Last
Contact Phone:
Contact eMail:
Contact or Business/Agency Address:
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Nature & Purpose of Disclosure
How may we exchange information with this contact? *
*
provide to
receive from
exchange with
What type of information may we exchange?
*
The most common options are pre-selected. Please check/uncheck options to match your preference.
Assessments/Summaries
Diagnosis
Diagnostic Interview
Medical History & Physical
Neuro/Psychological Testing
Case Plans/Notes
Discharge Summary
Medication Information
Urinalysis/Lab Tests
Emergency Contact
Treatment/Case Plans
Consultations
Legal Information
Psychotherapy Notes
Other
Other information type:
In what format may we exchange information?
*
Verbally
In-Person Conference
Written Questionnaire
Mailed/Faxed Correspondence
Secure/Encrypted eMail
Purpose for disclosure:
*
Assessment/Intake
Referral
Treatment Planning
Case Coordination
Discharge Planning
Consultation
Psychotherapy
Expiration of Authorization
Typically, releases of information automatically expire one year from the date signed. This allows us to share the necessary information for the duration of treatment involvement. If you wish to specify an earlier date of expiration, you may do so here.
I Don't Need to Change the Expiration
Enter a Different Date
Alternate Expiration Date
Date Format: MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.
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