Authorization For Mutual Disclosure Form printable pdf download

MERIDIAN PSYCHOLOGICAL ASSOCIATES

4401 N. CENTRAL AVENUE

INDIANAPOLIS, INDIANA 46205

(317) 923-2333 FAX (317) 923-2367

AUTHORIZATION FOR MUTUAL DISCLOSURE

CLIENT NAME: ________________________________________ DOB: ____________

I hereby authorize ___________________________________ and its employees to release

and/or exchange information with _____________________________________________

At (Contact Information/Address):_____________________________________________

DESCRIPTION OF INFORMATION TO BE RELEASED:

___Initial Evaluation ___Treatment Progress ___Clinical Notes ___Labs

___Psychological Tests ___Discharge Summary ___Diagnosis ___Treatment Plan

___School Records ___Verbal Exchanges

other:_____________________________________________________________________

THE ABOVE INFORMATION TO BE RELEASED FOR THE PURPOSE OF:

___Diagnosis and evaluation

___Formulation of treatment plan

___Psychological/psychiatric evaluation and assessment

___Comply with court ordered evaluations

other:______________________________________________________________________

___________________________________________________________________________

This authorization is subject to revocation at any time except to the extent that the provider

which is to make the disclosure has already taken action in reliance on it. I knowingly and

voluntarily waive the State of Indiana provision that this authorization expires in 180 days

and specify this authorization remain in effect for one (1) year or revocation in writing,

whichever occurs first. The above provider shall not be liable to the undersigned

client for any consequences of the disclosure by the provider of information authorized above.

__________________________________ ________________________________

Client Signature

Date of Signing

__________________________________ ________________________________

Witness

Guardian or Custodial Parent

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 ANY FURTHER DISCLOSURE OF IT

WITHOUT SPECIFIC WRITTEN AUTHORIZATION 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.

Authorization For Mutual Disclosure Form