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On-line Authorization for Release

This authorization may not be used for medical health information Correctional Healthcare Companies will not condition treatment on this authorization. Mental health information disclosed pursuant to this authorization may not be further disclosed except pursuant to authorization from the patient or patient's representative. If this authorization is for psychotherapy notes, it must not be used as an authorization for any other type or protected health information.
  • (enter name of facility)
  • (state the purpose of disclosure)
  • (enter ID # DOB and Patient's Name)
    The identified health information may be provided verbally or over the phone to the person or entity identified above.
    This authorization will expire (check one)
  • Signature of Patient or Person Authorized to Consent - I certify under perjury in the second degree, that the above facts are true and correct to the best of my knowledge.
  • MM slash DD slash YYYY