Release of Information
Please fill this out if you would like your clinician to speak with an outside provider.
Client's Name *
Your answer
Client's DOB *
MM
/
DD
/
YYYY
I hereby authorize my TWR Clinician *
Required
To release to:
Your answer
Or request from:
Your answer
The following information from my record, please be specific: *
If you selected specific info or other, please explain below
Your answer
This information is needed for the purpose of: *
If you selected other, please explain below
Your answer
I understand that the agency abides by Federal Confidentiality Regulations (42 CFR, Part 2) published July 1, 1975 which protect the confidentiality of my records, and that information contained in my records cannot be disclosed without consent unless otherwise provided for in the regulations.I understand that this directive is subject to revocation upon written request. Otherwise this consent will expire upon one year from date signed. I hereby release and hold harmless The Wellness Room from any liability for the release of any information provided in accordance with this directive.
Signature of Client or Legal Guardian *
Your answer
Date Signed *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy