C
R
F
ONFIDENTIALITY
ELEASE
ORM
I, __________________________________, authorize ________________________________
(Patient Name)
(Clinic, Counselor, or Doctor’s Name)
to disclose to ___________________________________________________ the copies of any
(Name and Location of Person(s)/Organization to Receive Information)
and all records and information which you may have in your possession. This includes all the
transmission of information and data via verbal and electronic contact.
These records and information include, but may not be limited to:
Hospital records, including that of attending nurses, physicians, health care personnel
and technicians.
Laboratory test results
Medical examination results
Medical opinions, diagnosis, progress notes, and recommendations
Treatment plans and progress
Description of treatment and prescriptions
Notes of conversations, phone calls, memoranda or any type of communication
concerning the overall treatment
I understand that the purpose of this disclosure is: ____________________________________
This authorization expires on: _____________________________________________, or when
____________________________________________, is no longer providing me with services.
I understand that my records are protected under Federal regulations and cannot be disclosed
without my written consent unless otherwise provided for in the regulations. I also understand
that I may revoke this consent at any time except to the extent that action has been taken in
reliance on it.
Print Patient Name________________________________________ Date_________________
Signature of Patient ____________________________________________________________
Date of Birth ______________________Social Security # ______________________________
Print Witness Name _______________________________________Date_________________
Signature of Witness ___________________________________________________________
ATTENTION RECIPIENT – Notice Prohibiting Redisclosure
This information has been disclosed to you from the records protected by Federal confidentiality rules 42
C.F.R. Part 2). The Federal rules prohibit you from making any further disclosure of this information
unless further disclosure is expressly permitted by the written consent of the person to whom it pertains
or as otherwise permitted by 42 C.F.R. Part 2. The Federal rules restrict any use of this information to
criminally investigate or prosecute any alcohol or drug patient.