Authorizaton Form For Mutual Release Of Client Information
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2AUTHORIZATON FOR MUTUAL RELEASE OF CLIENT INFORMATION
CLIENT NAME (PRINT)______________________________________
I request that information my current and/or past diagnoses, medication, therapy, treatment, insurance
status, billing , payment or other purpose (fill in here ____________________________________
be exchanged verbally and /or in writing between my psychologist, Gail Kalin, Ph.D (Licensed Clinical
Psychologist) and the following:
Name and Title _____________________________________________________________________
Relationship to you: __________________________________________________________________
(e.g. psychiatrist, previous therapist, family member, attorney, insurance, etc.)
Address:
______________________________________________________________________
______________________________________________________________________
Phone:
_________________________ Year(s) of Treatment ___________________________
Fax:
_________________________ Email: _______________________________________
In authorizing this mutual disclosure, I understand this information will be used solely for the purposes
of my treatment, evaluation, payment or ________________ (fill in if other), both now and in the future.
I understand that I have the right to meet with my clinician to inspect my mental health information
record.
I further understand that this information cannot be re-disclosed without my authorization and that the
law requires the following notice:
The unauthorized disclosure of mental health information violates the provisions of the District of
Columbia Mental health Information Act of 1978. Disclosures may only be made pursuant to a
valid authorization by the client or as provided in Titles III or IV of that Act. The Act provides for
civil damages and criminal Penalties for violations.
This consent is subject to revocation in writing at any time.
CLIENT SIGNATURE:__________________________________ DATE: ______________________
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