Authorization for Release of Information Form

Therapist*

I (client) hereby authorize use or disclosure of protected health information about me as described below.

Name*

First Last

The following specific person or class of persons or facility is authorized to make the requested use or disclosure:*

Specific description of information to be released (and date(s) of service):*

The information to be released will be used for the psychotherapeutic treatment of the client(s) in a manner that is consistently with all ethical and legal guidelines.

I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.

I may revoke or withdraw this authorization by notifying my therapist in writing of my desire to revoke it. However, I understand that any action already taken in advance of this authorization cannot be reversed, and my revocation will not affect those actions. I understand that the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.

This authorization will expire on the below date or 1 (one) year after the date of said authorization.*

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Phone

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Authorization for Release of Information Form

Philadelphia Institute for Individual, Relational & Sex Therapy

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