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Consent to Release Confidential Information
I ___________________________________ hereby authorize and request,
Name: ______________________________________
Address: ______________________________________
_______________________________
to release confidential information, including personal, psychological, psychiatric, drug/alcohol, medical records and opinions, resulting from my contacts with the above to:
Name: ______________________________________
Title/Functions: ______________________________________
Address: ______________________________________
_______________________________
Disclosure shall be limited to the following specific types of information:
______________________________________________________
______________________________________________________
Use of this information shall be limited to the following purpose(s):
______________________________________________________
______________________________________________________
I understand that any cancellation or modifications of this authorization must be in writing, and that I have a right to receive a copy of this authorization. A photocopy of this authorization shall be as effective and valid as the original.
This authorization shall remain valid until: ___________________________
I furthermore release all parties stated here within from any legal liability resulting from the release of this information, with the understanding that all parties involved will exercise appropriate safeguards while using this information
Signature ____________________________________ Date _______________
Signature ____________________________________ Date _______________
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