Release of Information Disclosure Form Rev. September 2022

Release of Information Disclosure Statement

Please fill in the form below
Today's Date*

MonthDayYear
Date
Client Legal Name*

First NameMiddle NameLast NameSuffix
Client Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
Email*
example@example.com
Provider to release information: *
Records Fee Agreement

Please read the following Records Fee Agreement for Provider Samantha Ervin, APRN.
If you have chosen other, please select from the list of providers who are no longer with Pattison Professional Counseling: *
If you have been unsuccessful in locating the name of the provider you saw in the previous two drop-downs, please provide us that information below: *
Information to be disclosed:*

Clinical Case NotesTreatment SummaryPsychological Testing ReportsBilling SummaryOther
Who would you like information released to?*

Self / Client GuardianAnother Facility / Provider:
Name of individual or facility to receive information:
Doctor Name, Facility Name, Lawyer Name, etc.
Fax Number of person/facility to receive information:

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you like information to be disclosed?*

E-MailFaxIn person
E-Mail Address: *
Fax Number: *

Area CodePhone Number
Purpose or need for disclosure*
Enter the purpose or need for the disclosure
Name of individual filling out form: *
Relationship to client if not self:
Guardian, enter your relationship to the client
Please attach a picture of your Photo I.D.: *

Browse Files

Cancelof
Disclosure Expiration (Please list an expiration for disclosure. If no date is entered, this disclosure will expire in one year from date of completion):

MonthDayYear
Enter the date the consent expires if sooner than one year.
Understanding and Agreement of Records Responsibility

Please read thoroughly. You must scroll the way through in order to submit this form.
You may revoke this consent to disclose the above-stated information by notifying the clinician disclosing the information and the person faxing/sending the information that you no longer desire to have your health information disclosed. You may contact these individuals by calling our office or sending them a written notice of your desire to no longer have your health information released.

Please mail your written notice to:

Pattison Professional Counseling & Mediation Center
259 E Oakdale Avenue, Crestview, Fl. 32539 | 850-682-1234
7 Vine Avenue NE, Ft. Walton Beach, Fl. 32548 | 850-863-2873
Signature of Client / Client Guardian*

Clear
Sign this document agreeing to the disclosure of the information
Should be Empty:

Release of Information Disclosure Statement

Records Fee Agreement

Understanding and Agreement of Records Responsibility