AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION (TO OOH)
The execution of this form does not authorize the release of information other than that specifically described below.
Your disclosure of the information requested on this form is voluntary.
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I, __________________________(Name)
Social Security #
Date of Birth
MM
/
DD
/
YYYY
authorize (name of organization)
Address:
and its duly authorized agents to release to:
Name of Individual (POC):
Title
Executive Director
Organization:
The following specific confidential information:
Psychological Reports/Diagnostic Information
Medical/Medication Information
Biopsychosocial History Information
HIV-Related Information
Alcohol and/or Drug Information
Treatment and/or Transition Plan Information
Other Information (Specify):
I understand the purpose of this release is _______________
I understand that (__________________)’s services are not contingent upon my decision to permit therelease of this information and I have consented freely, voluntarily, and without coercion, and that theabove information is accurate to the best of my knowledge. I understand that I have the right torevoke this authorization at any time except to the extent that action has already been taken tocomply with it. Without my express revocation,
this consent will expire on
MM
/
DD
/
YYYY
Person Served or Legal Representative
Date
MM
/
DD
/
YYYY
Witness
Date
MM
/
DD
/
YYYY
Submit
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