Authorization for Disclosure of Information

This form authorizes the use, disclosure, and exchange of your personal health information as required for treatment, coordination of care, or other specified healthcare operations.

Client Information

Date of Birth * Required

Authorization Details

I authorize the disclosure and/or exchange of the following information: (Select all that apply) * Required

Medical RecordsMental/Behavioral Health RecordsChiropractic RecordsNutrition and Dietary InformationOther

If you selected 'Other' above, please specify the records to disclose: Optional

To/With: Name of Recipient or Organization * Required

Recipient Contact Information (Phone, Email, or Address) * Required

The purpose of this disclosure is for: (Select all that apply) * Required

Continuity of CareCoordination of ServicesBilling and PaymentInsurance ClaimsLegal ReasonsOther

If you selected 'Other' for purpose, please specify: Optional

Expiration of Authorization

This authorization will expire: * Required

90 days from the date signedOn a specific date

If you chose 'On a specific date', please select the expiration date: Optional

Client Signature * Required

Signature

By signing below, I acknowledge that: I understand that my records may contain sensitive health information. I authorize the disclosure of my health information as specified above. I understand that I may revoke this authorization in writing at any time.

Authorization for Disclosure of Information

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