Authorization For Release Of Information
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1Mailing Address:
Tel: (720) 347-8559
2620 S. Parker Rd., Suite 272
Aurora, CO 80014
Fax: (720) 207-6885
AUTHORIZATION FOR RELEASE OF INFORMATION
Name: _____________________________________________ Date of Birth: ________________________________
Address: ___________________________________________ City, State, Zip: ______________________________
Phone: ________________________________________
Today’s Date: ____________________________________
I authorize the Center for Valued Living, PLLC:
to release information to
to obtain information from
___________________________________________
__________________________________________
Name of Person, Provider or Facility
Address
__________________/________________________
__________________________________________
Phone # / Fax # (Include area code)
City, State, Zip Code
PURPOSE OF THIS REQUEST:
TYPE OF RECORDS / COMMUNICATION AUTHORIZED:
(check one)
Continued Healthcare
Insurance
Legal
(check all that apply)
Personal
Psychological Testing
Psychiatric/Psychological Evaluation and/or Treatment
Social Security / Disability
Other
Medical Evaluation and/or Treatment
Disordered Eating Evaluation and/or Treatment
Drug/Alcohol Evaluation and/or Treatment
Verbal Communication with Person, Provider, or Facility
SPECIFIC INFORMATION AUTHORIZED: (
select all that
)
apply
Assessment Reports
Clinical Notes
SPECIFIC INFORMATION NOT AUTHORIZED:
(please
Diagnostic Impression
Consultation Reports
describe thoroughly)
Treatment Summary/Plan
Other: (please describe)_
_____________________________________________________
___________________________________________________
_____________________________________________________
One-time Use/Disclosure: I authorize the one-time use or disclosure of the information described above to the
person/provider/organization/facility/program(s) identified. My authorization will expire:
When the requested information has been sent/received.
90 days from this date.
Other: __________________________________________
Periodic Use/Disclosure: I authorize the periodic use/disclosure of the information described above to the
person/provider/organization/facility/program(s) identified as often as necessary to fulfill the purpose identified in this
document. My authorization will expire:
When I am no longer receiving services from the Center for Valued Living, PLLC.
One year from this date.
Other: ____________________________________
Signature of Client: _________________________________________ Date: __________________
Relationship to Client
(if requester is not the client):
Parent
Legal Guardian
Other: ________________________
Reason client is unable to sign:
Minor
Deceased
Gravely Disabled
Other: ________________________
CVL rep signature: ____________________
Print name: __________________________________
Date: ________________
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