Release of information consent form Release of Information Consent Form 12 EmailThis field is for validation purposes and should be left unchanged. Instructions Complete the information below. Click Next. Read the consent statement. Press “Previous” to go back and make corrections. You will confirm the entered data on the next page. Signatures will be taken at the office visit. Click Submit. Your consent form is ready to be printed. Print the completed consent form and bring it to your next appointment. Click here to download and print a blank consent form. Your Name, Patient or Parent/Guardian(Required) First Last Name of Patient, if Minor First Last Name of Authorized Office(Required)Is the Authorized Office Sending Information TO us or Receiving Information FROM us?(Required) To From Offices Is information is being sent TO or FROM the following Offices?(Required) To From Office 1 Name(Required)Office 1 PhoneOffice 1 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Office 2 Name Release of Information Consent Form Instructions Complete the information below. Click Next. Read the consent statement. Press “Previous” to go back and make corrections. You will confirm the entered data on the next page. Signatures will be taken at the office visit. Click Submit. Your consent form is ready to be printed. Print the completed consent form and bring it to your next appointment. Click here to download and print a blank consent form. I authorize the office listed above to send and/or receive my information to and from the agencies and providers I have identified for purposes related to my care. Information to Transmit (check all that apply) Academic Testing Behavior Programs Case Notes Intelligence Testing Results Medical Reports Personality Profiles Psychological Testing Results Service Plans Summary Reports Vocational Testing Progress Reports Psychological Reports Other (specify) Other (specify) Send entire record Send records for date range (choose starting and ending dates) Start DateEnd DateThe above information will be used for the following purposes: Planning Appropriate Treatment or Program Continuing Appropriate Treatment or Program Determining Eligibility for Benefits or Program Case Review Updating Files Other (specify) Other (specify)I understand that I may revoke this consent at any time by providing written notice, and after one year this consent automatically expires. I have been informed what information will be given, it’s purpose, and who will receive the information. Click submit below to view and print the consent form. BRING the consent form to your next visit.
