Authorization to Obtain/Disclose Protected Health Information

  • Please complete all applicable fields.  This form will allow your therapist to release/obtain protected health information to/from the person or place of your choosing.  If you have questions regarding this form, please speak with your therapist before submitting.

  • 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.