AUTHORIZATION TO RELEASE CONFIDENTIAL MENTAL HEALTH INFORMATION
I hereby authorize release of my confidential mental health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health care provider, a mental health care provider, or a health plan, the released information may no longer be protected by federal privacy regulations.
The released information will be used solely for the purpose of psychotherapeutic treatment planning and coordination of care unless specifically noted as follows:
This authorization is valid throughout the duration of treatment.
Carefully read the following statements before signing this authorization:
- I may revoke this authorization at any time in writing, except as to information released before the receipt of the revocation.
- I understand that my mental health care will not be denied if I refuse to sign this authorization.
- Information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer subject to privacy protections.
- I am entitled to a copy of this authorization.
Signature of Client or Client’s representative Date
(Form MUST be completed before signing)
Printed Name of Client’s representative: Date
What is the representative’s authority to act on behalf of the Client?
**YOU MAY REFUSE TO SIGN THIS AUTHORIZATION**