Authorization to Release Confidential Information Pursuant to The Confidentiality of Medical Information Act
I hereby request and authorize ____________________________, doctor, therapist, school agency, etc.
___________________________________________________________ street address,
___________________________________________________________ city,
___________________________________________________________ state and zip code,
and Sanctuary By The Sea Counseling Services (SSCS) and/or Crystal Duncan, LCSW CA61763 to exchange all pertinent records and information concerning the psychological and/or medical history with each other regarding the below listed client. This release shall remain in effect for six (6) months and can be extended to twelve (12) months and may be revoked at any time in writing by the undersigned.
Name of Client ____________________________________________________________________
___________________________________________________________________ street address,
___________________________________________________________________ city,
___________________________________________________________________ state and zip code,
Date of Birth __________________________
Signature ______________________________________________________________
Date Signed ____________________________________________________________
Relationship to Client ____________________________________________________
I would like a copy of this release: __ Yes __ No
NOTICE TO RECEIVING FACILITY/THERAPIST: You may not disclose any of this information unless the person who consented to this disclosure specifically consents to such disclosure.
I understand that there is a potential for re-disclosure of this information by the recipients and, if that occurs, the information may not be protected by federal law.
I hereby request and authorize ____________________________, doctor, therapist, school agency, etc.
___________________________________________________________ street address,
___________________________________________________________ city,
___________________________________________________________ state and zip code,
and Sanctuary By The Sea Counseling Services (SSCS) and/or Crystal Duncan, LCSW CA61763 to exchange all pertinent records and information concerning the psychological and/or medical history with each other regarding the below listed client. This release shall remain in effect for six (6) months and can be extended to twelve (12) months and may be revoked at any time in writing by the undersigned.
Name of Client ____________________________________________________________________
___________________________________________________________________ street address,
___________________________________________________________________ city,
___________________________________________________________________ state and zip code,
Date of Birth __________________________
Signature ______________________________________________________________
Date Signed ____________________________________________________________
Relationship to Client ____________________________________________________
I would like a copy of this release: __ Yes __ No
NOTICE TO RECEIVING FACILITY/THERAPIST: You may not disclose any of this information unless the person who consented to this disclosure specifically consents to such disclosure.
I understand that there is a potential for re-disclosure of this information by the recipients and, if that occurs, the information may not be protected by federal law.
