Authorization for Use or Release of Information

Person/Entity Name:

Person/Entity Address:

Person/Entity Telephone:

The purpose of the use or disclosure is:
At the request of the patient and/or legal guardian;
To provide Treatment, Payment and/or Operations Processes;
Other:

The information to be used or disclosed includes only those items checked below, with respect to services provided on or around (insert dates of service): *If this line is left blank, the treatment dates covered by this authorization are from preadmission to discharge and claims resolution.

The information to be used or released includes:
Discharge Summary;
Psychiatric Evaluation;
Treatment Plans;
Laboratory Data;
Consultation Reports;
Assessments;
Billing/Financial Records;
Letter with date and physician name;
Letter with date, physician name, and diagnosis;
History and Physical Exam;
Psychological Testing;
X-ray Report;
Medication Records;
Verbal Communication with:
Other:

Patient's Authorized Representative: