Authorization for Release of Protected Health Information (PHI) Mental Health Record

By signing this form, you permit your health care providers identified below to disclose and/or receive your confidential personal health information. Please include any therapist or family members you include in treatment communication.

First Name*

Last Name*

Email*

Release applies to:

Name*

Phone*

Other Personal Health Information*

I understand that I can revoke this authorization at any time by giving my written revocation to the disclosing provider. My revocation is not effective as to disclosures already made and actions already taken in reliance upon this authorization. I am authorizing disclosure of information protected under Federal law. This information, once disclosed, may be subject to re-disclosure by the recipient and no longer protected by state or Federal law.