Sample New Client Information Form - Insurance Page 3
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4CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION
I, ____________________________ authorize __________________________,
Client/Parent/Guardian
Therapist’s Name
(if a minor) regarding, _____________________________.
Mark the one(s) that apply to you:
○
To disclose and discuss clinical and treatment information with,
________________________, or __________________.
Other Mental Health Provider’s Name
Attorney/Law Firm
○
To exchange clinical information, such as diagnosis, treatment goals, and
medication issues with my Physician, ___________________, for the
Physician’s Name
purpose of treatment planning and coordination.
Contact phone number and address:
_____________________________________________________________
○
To disclose and discuss clinical and treatment information with,
_________________________ and/or _____________________
School Name
Counselor /Teacher
○
To disclose and discuss clinical and treatment information with,
_________________________ please explain:
Other
_____________________________________________________________
○
I prefer that no clinical and/or medical information be released at this time.
I, the undersigned, understand that I may revoke this consent at any time except to the extent that action has been
taken in reliance on it and that in any event this consent shall remain in effect unless revoked or replaced.
___________________________
Specification of the date, event or condition upon which consent expires:
________________________________
_________________________
Client Name (Please print)
Witness
________________________________
_________________________
Client or Guardian’s Signature
Date
To the party receiving this information: This information has been disclosed to you from records whose confidentiality is
Protected by federal law. Federal regulations (42 CFR Part 2) prohibit you from making further disclosure of it with the
specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general
authorization for the release of medical or other information is not sufficient for this purpose.
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