Consent for the release of confidential information

CWID:

Date of Birth:

Month

Day

Year

hereby authorize

Release

Obtain

the following psychiatric, medical and alcohol and drug information:

Other:

to/from

(Name)

Address:

Dates of Services

The above listed information is to be disclosed for the specific purpose of:

I understand this consent is subject to written revocation by the undersigned at any time except to the extent that action has already been taken to receive the information. This consent shall automatically expire one year from the date signed, unless otherwise specified below.

Expiration Date:

Month

Day

Year

Dated

Month

Day

Year

Client Signature

Parent, Guardian or Authorized Representative of Client

TO THE PARTY RECEIVING THIS INFORMATION: This information has been disclosed to you from the records whose confidentiality maybe protected by federal law. Federal Regulations (42CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent 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. FOR PATIENT RECORDS APPLICABLE UNDER FEDERAL LAW 42 CFR PART 2.

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