Authorization to Release and Exchange Protected Health Information Client Name Date of Birth I, (client/parent/legal representative), hereby authorize the use or disclosure of my protected health information as follows. The information that may be used or disclosed includes (check applicable box) All treatment recordsRecord of treatment during the following time periodResults of Psychological/Neuropsychological EvaluationOther records (describe) This information may be disclosed to: I authorize: The parties named above to mutually exchange information. For the purpose of: At the client/personal representative/legal guardian’s requestContinued medical careLegal purposesDisability Determinations This authorization expires (check applicable box): One year from the date this Authorization to Disclose is signed. I understand that I have the right to revoke this Authorization at any time by means of a written letter. However, I also understand my withdrawal will not be retroactive, that is, it will not apply to the transfer of information that has already taken place. I have read and understand this authorization. I am the client or am authorized to act on behalf of the client to sign this document for the use or disclosure of protected health information. I have signed it voluntarily and of my own free will. I understand that the statements in this authorization are binding. Signature of Client/Parent/Legal Guardian Date Δ
