Authorization for Disclosure Form | Glori Gray, Psy.D., P.C.

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Authorization for Disclosure Form | Glori Gray, Psy.D., P.C. | Mind Mosaic Psychology

This form when completed and signed by you, provides authorization for Glori Gray, Psy.D., P.C. | Mind Mosaic Psychology to release/receive protected information from your clinical record to/from the person(s)/organization designated within the document.

Email *

Client's Full Name *

Client's Date of Birth: *

YYYY

Authorization

I DO NOT authorize:

I DO Authorize:

Clear selection

Glori Gray, Psy.D., P.C. | Mind Mosaic Psychology to RELEASE the following information from the records of the above listed client for services provided during the time period of the last year (or as otherwise relevant)

Please CHECK item(s) to indicate specific authorization *

Progress to date

Test Results / Evaluation Report

Behavioral Checklists / Narrative Forms

Educational/Functional Status

All of the above

IEP/504

Other:

Required

I authorize Glori Gray, Psy.D., P.C. | Mind Mosaic Psychology to release or receive the following information from the records of the above listed client for services provided during the time period of the last year (or as otherwise relevant).

Please CHECK item(s) to indicate specific authorization *

Evaluation Report

Progress to date

Test Results / Evaluation Report

Symptoms

Behavioral Checklists / Narrative Forms

Treatment Summary

Diagnosis

Treatment Plan

Prognosis

Functional Status

All of the above

Required

THIS INFORMATION SHOULD ONLY BE RELEASED TO OR RECEIVED FROM:

Please write the FULL NAME and/or ORGANIZATION NAME (if applicable):

(please list ONE person, organization, school, etc.)

What is person/organization's relationship with the client? *

Write the contact information below (please be sure to include email address): *

THIS INFORMATION SHOULD ONLY BE RELEASED TO OR RECEIVED FROM:

Glori Gray, Psy.D., P.C. | Mind Mosaic Psychology
360 North Caswell Road | Charlotte, NC | 28204
(o) 704.765.2549
(f) 704.765.4749

I am requesting that my clinician release and/or receive this information for the following reason(s): *

"At the request of the individual" is all that is required if you are the client and do not desire to state a specific purpose

At the request of the individual

Other:

This authorization shall remain in effect until: *

1 year from now

Other:

You have the right to revoke this authorization, in writing, at any time by sending such written notification to the office address. However, your revocation will not be effective to the extent that Glori Gray, Psy.D., P.C. | Mind Mosaic Psychology has taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that my therapist generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party. I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPPA Privacy Rule.

Client/Parent/Guardian''s Full Name *

Client/Parent/Guardian''s Signature *

By signing this form electronically, you are agreeing to the terms and conditions stated herein.

Today's Date *

YYYY

Others

If you have any additional people with whom you would like to sign a release, please submit another response below.

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Gray Psychological Associates.

Does this form look suspicious? Report

Forms