Authorization to Release and Receive Information for Adult and Collaterals in Treatment

Dr. Tracy Bennett Psychological Services, Inc.

Tracy Bennett, PhD
Licensed Clinical Psychologist, PSY15696
340 Rosewood Avenue, Suite A
Camarillo, CA 93010
DrTracy@DrTracyBennett.com
805-383-0882
Authorization to Release and Receive Information for Adult and Collaterals in Treatment
Your Name*

First NameLast Name
I, the undersigned, hereby authorize the party(ies) named below to speak to and release records to Dr. Tracy Bennett and obtain information or my records from Dr. Bennett. Specific information that I authorize for release and receipt is detailed below.

The information checked below may include anything said in session by myself and any collaterals who join me in session. It also may include information emailed, mailed, or texted to Dr. Bennett for the purposes of my treatment. I understand that such information may be integrated into my medical file, and that Dr. Bennett will preserve the confidentiality of such information according to the policies based on applicable portions of the California Welfare Institutions Code Section 4514.
I give permission to Dr. Tracy Bennett to release to and obtain records from the following party (ies) (up to 4):
Party to/from which I authorize release/receipt*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Second party to/from which I authorize release/receipt (if applicable)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Third party to/from which I authorize release/receipt (if applicable)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Fourth party to/from which I authorize release/receipt (if applicable)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Records to be exchanged include (Check all that Apply)

Information relevant to coordinating care (including but not restricted to attendance, diagnosis(es), and treatment plan)Statement of progress including participation and termination detailsTreatment summaryFinancial statementsALL OF THE ABOVEAll records excluding treatment notesAll records including treatment notesOther
I understand that that this release is valid for the extent of treatment unless revoked in writing. I further understand that I may revoke this authorization at any time in writing. If you wish this release to be valid for a shorter term, please indicate the date it shall expire. DO NOT ENTER A DATE HERE UNLESS YOU WANT A SPECIFIC EXPIRATION DATE.
Please print your name*

First NameLast Name
By signing below, I show that I have read and understood the terms of this release of information. I understand that Dr. Bennett does not have control over what happens to records after their release to other parties. In consideration of this consent, I hereby release Dr. Tracy Bennett from any legal liability resulting from the release of this information. *

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