Consent to Release Confidential
Information
|
| I
___________________________________ hereby authorize and
request, |
 Name:
______________________________________ |
| Address:
______________________________________ |
|
_______________________________ |
| to
release confidential information, including personal,
psychological, psychiatric, drug/alcohol, medical records and
opinions, resulting from my contacts with the above to: |
| Name:
______________________________________ |
| Title/Functions:
______________________________________ |
| Address:
______________________________________ |
|
_______________________________ |
|
Disclosure shall be limited to
the following specific types of information: |
| ______________________________________________________ |
| ______________________________________________________ |
|
Use of this information shall be
limited to the following purpose(s): |
| ______________________________________________________ |
|
______________________________________________________ |
| I
understand that any cancellation or modifications of this
authorization must be in writing, and that I have a right to
receive a copy of this authorization. A photocopy of this
authorization shall be as effective and valid as the
original. |
| This
authorization shall remain valid until:
___________________________ |
| I
furthermore release all parties stated here within from any
legal liability resulting from the release of this information,
with the understanding that all parties involved will exercise
appropriate safeguards while using this information |
| Signature
____________________________________ Date _______________ |
| Signature
____________________________________ Date _______________ |
