Client's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Date Authorization Initiated

MM

DD

YYYY

The purpose or need for this authorization is:

Continuity of care

Other

Information to be released

The specific uses and limitations of the types of health information to be released are as follows: (Check all that apply)

Treatment Coordination

Treatment Planning

Diagnostic Refinement

Other

Such disclosures shall be limited to the following specific types of information:

Psychiatric diagnosis(es)

Dates of Treatment

Treatment Summary

Full Treatment Record

Other

Client Electronic Signature

Per the ESIGN Act, your esignature is legally binding. By signing your name electronically below, you are agreeing that your electronic signature (or esignature) is the legal equivalent of your manual signature.

First Name

Last Name

Date of Signing

MM

DD

YYYY