Sample: Consent to Release Confidential Information

 

Client name:                                                                                                                           

Confidential information may be released to or obtained from the following person(s) or organizations.

 

Name/Title/Organization                                                            Phone number

 

Address

 

Counselor                                                                              Phone number                                                    

 

Address

The requested information is needed or will be provided for the following purposes:

_____ to provide ongoing treatment/counseling

_____ emergency only

_____ to coordinate treatment/counseling efforts with my employer/school personnel

_____ to obtain insurance/employer/church/government benefits

_____ to enable judges, attorneys, probation/parole officers to support treatment goals or  

           make legal decisions on my behalf.

 

I hold harmless this counselor in regard to use of the information for release or exchange of confidential information including information regarding HIV, AIDS, sexually transmitted diseases, mental disorders, and substance abuse. I understand that this form is not required as a condition of treatment or counseling and that it may be revoked by me in writing at any time except to the extent that the action has already been taken. I knowingly and voluntarily waive the Indiana law provision that the consent expires in sixty (60) days and specify that this consent remain in effect until:_________________________________.

Any further disclosure of information sent in reliance on this authorization is prohibited except upon specific consent by the person to whom it pertains.

 

I have read and understand the above and acknowledge that it was properly completed prior to my signature. A photocopy of this authorization is as authentic as the original signed authorized release. An original will be retained in my records.

 

 

Client/Guardian Signature                     Date of Birth               SSN                              Date

 

 

 

 

 

Counselor/Witness Signature                                                Date