PRIMARY DOCTOR INFORMATION FOR 17 & UNDER

Authorization for Release of Behavioral Health and/or Medical Information
MM slash DD slash YYYY

I authorize that the requested information may be
Address

I authorize that the requested information may be
Contact Name: Life Solutions Psychotherapy
Program Address: 20 Arcampus Drive Rochester, New York 14612
Phone: (585) 225-9720 Fax: (585) 225-6898

PURPOSE OF THIS REQUEST:

TYPE OF INFORMATION AUTHORIZED:

TYPE OF RECORDS REQUESTED:

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

SPECIFIC INFORMATION AUTHORIZED:

One-time Use/Disclosure: I authorize the one-time use or disclosure of the information described above to the person/provider/organization/facility/program(s) identified
My authorization will expire:

Periodic Use/Disclosure: I authorize the periodic use/disclosure of the information described above to the person/provider/organization/facility/program(s) identified as often as necessary to fulfill the purpose identified in this document.
My authorization will expire:

I understand that:
  • I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment.
  • I may cancel this authorization at any time by submitting a written request to the Strong Health Program address above, except where a disclosure has already been made in reliance on my prior authorization.
  • If the person or facility receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information stated above could be redisclosed.
  • If the authorized information is protected by Federal Confidentiality Rules 42CFR, Part 2, it may not be disclosed without my written consent unless otherwise provided for in the regulations.
  • Release of HIV-related information requires additional authorization.
  • If the medical record information is not sent to another care provider there may be a charge for the requested records.
Relationship to Patient (if requester is not the patient):