Patient Name:*
First Last
Address*
Street Address City State ZIP Code
Phone*
Date of Birth*
MM slash DD slash YYYY
I hereby authorize:*
Elena Kaiser
To use or disclose to (name of person)*
First Last
Person's Address*
Street Address City State ZIP Code
Person's Phone Number
Person's Email
Release Type*
- Two-Way Release
- One-Way Realease
Description of the specific information to be used or disclosed*
- Treatment Summary
- School functioning
- Psychological testing/evaluation
- Follow-up care
- Evaluation
- Other
You selected "Other". Please specify below*
This authorization shall remain in effect from the date signed below until:*
MM slash DD slash YYYY
I understand that: • I may inspect or copy the protected health information to be used or disclosed. • I may revoke this authorization in writing by contacting your office at the address above. • Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer protected by HIPAA. • I may refuse to sign this authorization and that you will not condition treatment or payment on me providing this authorization (except to the extent that the authorization is for research-related treatment, in which case you may refuse to provide that research related treatment.
Is the patient older than the age of 12?*
Child's Printed name
Child's Signature
Printed name*
First Last
Signature*
Date*
MM slash DD slash YYYY
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