Authorization to Disclose Information

Client Information *

Client Name

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Client Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Home Phone *

(###)

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Client Work Phone

(###)

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Client Cell Phone

(###)

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By clicking this box, I hereby authorize The Brandywine Center to release a copy of my mental health information to the person/facility below *

Phone *

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Authorization *

MM

DD

YYYY

Authorization to expire on *

MM

DD

YYYY

Information To Be Released

My entire mental health record

Only those portions pertaining to the below listed specific provider and/or dates of treatment

Authorization for Psychotherapy Notes ONLY (Important: If this authorization is for Psychotherapy Notes, you must not use it as an authorization for any other type of protected health information.)

Other

Purpose of Information Release

Further mental health issues

Applying for insurance

At the request of the individual

Payment of insurance claim

Vocational rehab, evaluation

Legal investigation

Disability determination

Other

Authorization and Signature *

I authorize the release of my confidential protected health information, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be re-disclosed by the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected health information.

If signed by a personal representative, indicate your relationship to the client and/or reason and legal authority for signing

Patient is a minor

Patient is incompetent

Patient is disabled

Patient is deceased

Legal authority: parent

Legal authority: legal guardian

Legal authority: representative of deceased