Therapy Release of Information Form
Authorize the release of your therapy records by completing this Therapy Release of Information Form. Please review each section carefully and provide accurate information.
Patient/Client Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Person or Organization to Receive Information
*
Recipient's Email or Fax Number
*
Information to be Released
*
Session summaries
Treatment plans
Progress notes
Discharge summary
Other
Purpose of Release
*
Continuity of care
Personal use
Legal request
Other
Time Period of Records to be Released
*
Preferred Delivery Method
*
Email
Fax
Mail
Authorization Expiration Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit Authorization
Submit Authorization
Should be Empty: