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Release of Information

This document is a request/authorization form for Eastern Atlanta Behavioral Health LLC to release confidential records and information about a client. It provides the client's name, social security number, date of birth, and authorizes the release of diagnoses, treatment goals, social history, treatment history, evaluation results, and treatment recommendations to another agency. The client signature and date confirms their understanding and consent to the release of their private health information for a period of one year unless an earlier date is specified.

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norniellar
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592 views

Release of Information

This document is a request/authorization form for Eastern Atlanta Behavioral Health LLC to release confidential records and information about a client. It provides the client's name, social security number, date of birth, and authorizes the release of diagnoses, treatment goals, social history, treatment history, evaluation results, and treatment recommendations to another agency. The client signature and date confirms their understanding and consent to the release of their private health information for a period of one year unless an earlier date is specified.

Uploaded by

norniellar
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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1353 Jennings Mill Rd.

Suite C Box 7
Bogart, GA 30622
Phone:706-357-5467 Fax:706-357-5468

Request/Authorization to Release Confidential Records and Information


I _______________________________ SS#: _______________________ DOB: __________ hereby authorize
Eastern Atlanta Behavioral Health LLC to release to or to obtain from:

Agency or Facility:_________________________________________________________________________

Address:__________________________________________________________________________________
__________________________________________________________________________________________
Information related to: diagnoses, treatment goals, social history, treatment history (inpatient and/or
outpatient), evaluation results, treatment recommendations, any other related information for the purpose of:
___________________________________________________________________________________
I have read or had explained to me and fully understand this request/authorization to release records and
information, including the nature of the records, their contents and the consequences and implications of their
release. This request is entirely voluntary on my part. I understand that I may revoke this authorization at any
time, except to the extent that action based on this consent has already been taken. I understand that the
authorization will remain in effect for:

_____ One (1) Year unless I specify an earlier date here __________________
_____ The period necessary to complete all transactions related to this authorization.

__________________________________
Signature of Client

______________________________
Printed Name

___________
Date

__________________________________
Signature of Parent/Guardian/Representative

______________________________
Printed Name & Relationship

____________
Date

I witnessed that the individual listed above understood the nature of this request/authorization and gave his/her
consent verbally due to an inability to physically provide a signature.
__________________________________
Signature of Witness

____________________________
Printed Name/Relationship

__________
Date

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