Authorization To Release Information Form
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1AUTHORIZATION TO RELEASE INFORMATION
I authorize SAFE HARBOR CHRISTIAN COUNSELING to release to, and receive from
______________________________________________________________________________________
(Name)
_____________________________________________________________________________________
(Address)
[ ] School System
[ ] Hospital
[ ] Private Clinician
[ ] Pediatrician
[ ] Court System
[ ] Other
[ ] Family Member/Support person
the following information on ___________________________________________
________________
(Patient Name)
(DOB)
_____ Medical Records
_____ Academic Records/Educational Evaluation
_____ Medical History/Physical
_____ Treatment Plan/Patient Progress
_____ Psychological Evaluation
_____ Discharge Summary
_____ Social History
_____ Special Education File
_____ Neurological Evaluation
_____ Immunization Records
_____ Results of Drug and Alcohol
_____ Other (Specify) _______________________________
Treatment/Testing
For the purpose of: ______________________________________________________________________
Approximate dates of service: _____________________________________________________________
I have been informed of the type of information being released, the benefits and disadvantages ( if any ),
and understand that treatment services are not contingent upon my decision concerning the signing of this
release. I have also been informed that my photocopied signature is as valid as the original.
Signature of Patient: __________________________________________________ Date: ____________
Signature of Parent/Guardian: __________________________________________
Date: ____________
(If patient is a minor)
Signature of Witness: _________________________________________________
Date: ____________
Note: Remember to ask for permission to release information to any key person who has worked with the
patient and family ( i.e. probation officer, hospital clinician, private practice clinician, teacher, guidance
counselor, attorney, etc. )
As required by Section 2.32(a) PROHIBITION ON DISCLOSURE –rule: “This information has been
disclosed to you from records whose confidentiality is protected by Federal Law. Federal regulations
( 42 CFR Part 2 ) prohibits you from making any further disclosure of it without the specific written
consent of the person to whom it pertains or 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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