Authorization To Release Protected Health Information
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1Authorization to Release Protected Health Information
Client Number
Name (First, Middle, Last)
Birth Date (Month, DD, YYYY)
Instructions: If any section is incomplete, this form may be invalid.
Release, Obtain, or Exchange Information To/From
Release, Obtain, or Exchange Information To/From
Midwest Psychological Services, 2501 Hanley Rd,
Midwest Psychological Services, 2501 Hanley Rd,
Suite 202, Hudson, WI 54016-8705
Suite 202, Hudson, WI 54016-8705
Provider: ____________________________________
Provider: ___________________________________
Other
(Specify facility/Individual & address below, including
Other
(Specify facility/Individual & address below, including
phone/fax if known)
phone/fax if known)
___________________________________________
__________________________________________
___________________________________________
__________________________________________
___________________________________________
__________________________________________
___________________________________________
__________________________________________
Purpose of Release
Treatment/Continued Care
Personal
Legal Purposes
Application for Insurance
Disability Determination
Payment on Insurance Claim
Other ______________________________________________________________________________________________
Information to be Released
Admissions/Intake
Diagnostic Impressions
Progress Notes
Psychiatric Evaluations
Academic Records/ School Functioning
Discharge/Treatment Summary
Social/Court Services Summary
Psychological Testing/Evaluation
Phone Consultation
Laboratory tests
Other _________________________________________________________________
I understand the information to be released may include records related to behavior and/or mental health care, alcohol and drug abuse
treatment, HIV/AIDS, and genetics. This authorization may be revoked at any time except to the extent that action has been taken in reliance
upon it. Revocation must be made in writing to the provider/facility releasing the information. The provider/facility will not condition treatment
on whether I sign the authorization. I may be charged for the copies in accordance with state law. Information used or disclosed pursuant to
this authorization may be subject to the redisclosure by the recipient and may no longer be protected by federal law.
ATTENTION: This is a legal document. Please read carefully. By signing, you agree that you understand and accept the terms
on this form.
•
If the patient is 18 years of age or older, the patient must sign and date the form.
•
If the patient is 18 years of age or older and is incapable of signing, a legally authorized substitute may sign and date
the form.
Please indicate your legal authority and include documentation of your relationship:
o
Legal guardian or Conservator
Health Care Agent (Health Care Power of Attorney)
•
If the patient is 17 years of age or younger, the patient’s parent or legal guardian must sign and date the form, unless
an exception exists under state or federal law. Please indicate your relationship:
Parent
Legal Guardian
This authorization will expire one year from the date of signing unless I indicate an earlier date or event here: ________________
Signature (Required)
Date Signed (Required) (Month, DD, YYYY)
Printed Name of Person Signing (If Not Patient)
Mailing Address of Client – Street
City
State
ZIP Code
Phone
(781) 381-1980
pg.
1
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