Client Information

Client Name*

First Middle Initial Last

DOB*

Client Address*

Street Address Address Line 2 City State ZIP Code

Client Home Phone*

Client Work Phone

Client Cell Phone

Client Email*

By clicking this box, I hereby authorize The Brandywine Center to release a copy of my mental health information to the person/facility below

Recipient Information

Name of person/facility to receive medical information*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Date of Authorization*

Authorization to expire on:*

Or upon the happening of the following event:

Information To Be Released

(Note: Requests for release of psychotherapy notes cannot be combined with any other type of request.)

My entire mental health record

Only those portions pertaining to the below listed specific provider and/or dates of treatment

Authorization for Psychotherapy Notes ONLY (Important: If this authorization is for Psychotherapy Notes, you must not use it as an authorization for any other type of protected health information.)

Other

Purpose of Information Release

Further mental health issues
Applying for insurance
At the request of the individual
Payment of insurance claim
Vocational rehab, evaluation
Legal investigation
Disability determination
Other

Authorization and Signature*

I authorize the release of my confidential protected health information, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be re-disclosed by the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected health information.

Please type your name as a virtual signature of this form*

If signed by a personal representative, indicate your relationship to the client and/or reason and legal authority for signing:

Patient is a minor
Patient is incompetent
Patient is disabled
Patient is deceased
Legal authority: parent
Legal authority: legal guardian
Legal authority: representative of deceased

Authorization to Disclose Information

Client Information

Recipient Information

Information To Be Released