Authorization To Use And Disclose Health Information Form
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2AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION
Patient’s Name: ________________________________ Date of Birth: ____________
Social Security Number: ______________________ Home Telephone: ____________
Address: _______________________________________________________________
(Street)
(City/State)
(Zip Code)
I authorize the use and disclosure of the individually identifiable health information about me that is
described below by Educational & Psychological Services, Ltd. for the specific purposes listed below. I
understand that such uses and disclosures may only be made by, and only to, the persons or organizations
identified below.
Specific information to be used or disclosed (check applicable box/es)
Progress Notes
Psychological Evaluation
Psychiatric Assessments
Treatment Summary
Letter to my Physician
Initial Evaluation
Other: _______________________________________________________
_______________________________________________________________
Approximate dates of Treatment: ________________ to _______________
Facility using or disclosing the information:
Educational & Psychological Services, Ltd.
Purpose/s of the use or disclosure:
Continuation/Coordination of Care
Personal
Insurance Company
Legal
Other (describe) ______________________________________________
_______________________________________________
_______________________________________________
Person/s or organizations/s receiving the information:
Name: _________________________________________
Address: _______________________________________
_______________________________________
Telephone Number: (_____) ________-__________
I understand the following:
My decision to sign this form and authorize this use and disclosure of health information about me, as
described above, is entirely voluntary and I may refuse to sign this form. If this authorization relates to
the use or disclosure of mental health information, these are the consequences of my refusal to consent:
______________________________________________________________________________.
Educational & Psychological Services, Ltd. may not and will not condition mental health care
treatment or payment, or enrollment in a health plan or eligibility for health care benefits, upon my
signing this authorization for the requested use and disclosure.
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