Authorization to release information

Authorization to Release Mental Health Information

FROM YOUR CLINICIAL RECORD TO THE PERSON/ORGANIZATION YOU DESIGNATE

MM slash DD slash YYYY

I authorize PEOPLEinc. to exchange information with:

Address

Specific nature of information to be released:

Any or all of the following:
Info to Release
Info to Release 2

The information above is being released for the purpose of:

purposes 1
purposes 2

I understand that:

1. This consent will automatically expire one year from signing unless a different date of expiration is specified here:
MM slash DD slash YYYY
2. I have the right to revoke this authorization, in writing, at any time by sending such written notification to my provider's office. However, my revocation will not be effective to the extent that my provider has taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
(Adult or minor age 13 or over)
MM slash DD slash YYYY
Parent/Guardian of minor under age 13 or legally disabled client/patient (if applicable)
MM slash DD slash YYYY