Release of Information Form * Client's name ** I authorize Psychology of South Florida to: *SendReceiveThe following information:Medical history and evaluation(s)Mental health evaluationsDevelopmental and/or social historyEducational recordsProgress notes, and treatment or closing summaryOtherTo / From:Phone* Your relationship to client: *SelfParent/legal guardianPersonal representativeOther* The above information will be used for the following purposes:Planning appropriate treatment or programContinuing appropriate treatment or programDetermining eligibility for benefits or programCase reviewUpdating filesOtherConsent *I understand that this information may be protected by Title 45 (Code of Federal Rulesof Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 42(Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1,Part 2), plus applicable state laws. I further understand that the information disclosed tothe recipient may not be protected under these guidelines if they are not a health careprovider covered by state or federal rules.I understand that this authorization is voluntary, and I may revoke this consent at anytime by providing written notice, and after (some states vary, usually 1 year) this consentautomatically expires. I have been informed what information will be given, its purpose,and who will receive the information. I understand that I have a right to receive a copyof this authorization. I understand that I have a right to refuse to sign this authorization.If you are the legal guardian or representative appointed by the court for the client,please attach a copy of this authorization to receive this protected health information.Signature *DateWitness signature (if client is unable to sign):Witness dateSend MessagePlease do not fill in this field.
