Release of Information A Release of Information CommentsThis field is for validation purposes and should be left unchanged.AUTHORIZATION FOR RELEASE OF INFORMATIONClient NameDate of Birth MM slash DD slash YYYY Phone NumberI, authorize Solara Psychological Services to:**(Check all that apply)Authorize Release information to the party listed below Obtain information from the party listed below Exchange information with the party listed below Recipient of Information:Name/OrganizationAddressPhoneFaxInformation to Be Released (Check All That Apply): Psychological Evaluation Report Therapy Progress Notes Diagnosis and Treatment Plan Medication and Medical History Insurance and Billing Information Entire Record (except psychotherapy notes) Other (please specify) Other (please specify)Purpose of Disclosure Coordination of Care Insurance/Billing Legal Purposes Personal Request Other Other (please specify)Acknowledgment and Terms: I understand that this authorization is voluntary and that I may revoke it at any time by submitting a written request, except to the extent that action has already been taken based on this authorization. I understand that once my information is disclosed, it may no longer be protected under HIPAA regulations. This authorization expires one year from the date signed, unless otherwise specified:Expiration Date MM slash DD slash YYYY Client Rights: I have the right to receive a copy of this form. I have the right to refuse to sign this authorization, and my refusal will not affect my ability to obtain treatment. I understand that Solara Psychological Services cannot condition treatment, payment, or enrollment on signing this authorization. Signature(Client or Legal Representative)Relationship (if signed by Legal Representative):Date MM slash DD slash YYYY
