Release of Information

Authorization for release of mental health records
(also known as protected health information)

Client Full Name

Client Address

Name

Phone

Address

Fax

Date of Treatment

Information to be released (Please describe):

I understand that, unless withdrawn, this authorization will expire 180 days from the date of signature. A photocopy of this form will be considered as valid as the original.

I understand that I may revoke this authorization at any time by notifying optimal medicine at the address indicated above in writing. This authorization will cease to be effective on the date notified except to the extent action has already been taken in reliance upon it.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by federal privacy regulations. However, Other state or federal laws may prohibit the recipient from disclosing specially protected information, such as substance abuse treatment information and mental health information.

I understand that my refusal to sign this authorization will not jeopardize my right to obtain present or future treatment for psychiatric disabilities except where disclosure of the information is necessary for the treatment.

My healthcare and payment for my health care at Optimal Medicine will not be affected if I do not sign this form.

I understand that I can request a copy of this form after I sign it.

By signing below, I acknowledge that I have read and understand this authorization.

Date