RELEASE AUTHORIZATION

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Kelley Gray, MA, L.P.C., LLC

Licensed Professional Counselor

303.669.2769 • kelleygray.com • kelley@kelleygray.com

Client First Name

Client Last Name

Select an Address

Phone

Birthday

Client Name

hereby authorize Kelley Gray M.A., L.P.C. to release information

to and obtain information from:

Name of hospital, physician, clinic, school faculty, etc.

Phone

Fax

Authorization initiated by

Information to be Released:

Psychiatric Conditions/Treatment/Psychological Testing

Substance Abuse

Medical Information/Medications Prescribed

Treatment Summary/Recommendations/Consultation

Social History

Educational Information

Payment and/or Scheduling

This information will expire on

or upon occurence of the following event:

Event

Authorization and Signature: I authorize the release of my confidential protected health information, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be redisclosed by the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected health information.

Signature of Client/Guardian

Date

Signature of Client Representative

Relationship of Patient to Representative

RELEASE AUTORIZATION

RELEASE AUTHORIZATION

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

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