Authorization for the Use or Disclosure of Protected Health Information

Authorization for the Use or Disclosure of Protected Health Information

(HIPAA Authorization for Release of Information)
Individual Patient Name:*
Patient Date of Birth*

MonthDayYear
Date
Patient Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Release Information To:Receive Information From:
Name of Individual/Institution:*
Paper copyFaxElectronic CopyVerbal communication only
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Individual Receiving/Releasing Records
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number of Individual Receiving/Releasing Records
Please enter a valid fax number.Format: (000) 000-0000.
Email Address of Individual Receiving/Releasing Records*:
example@example.com
*Email is not a secure means of communication. We will encrypt email communications of your records unless you tell us you prefer we use unencrypted email. If you prefer we not encrypt our communications, please initial here: INITIAL HERE
Psychological TreatmentNeuropsychological AssessmentOther
Specific DatesAll Dates
Specific Dates:
Date* through Date*
Intake ReportTermination SummaryNeuropsychological report with summary of scoresNeuropsychological report without summary of scoresVerbal communication only (no records will be released)Other
PermittedProhibited
This authorization may be revoked by a written request to The Psychological Service Center at Washington University at at the address above, at any time except to the extent that action has already been taken in reliance on it. If not previously revoked, this authorization will be valid for 90 days or as specified by this date or event triggering expiration: Date or Event
I understand the nature and purpose of the authorization, and I had the opportunity to ask questions about it. I understand that I may refuse to sign this authorization without impact on my ability to receive treatment or benefits that I am entitled to. I understand that the information to be released may be subject to re-disclosure by the recipient(s) and may no longer be protected by the privacy regulations.
Signature of Patient or Authorized Representative*

Clear
Printed Name of Patient or Authorized Representative*
Relationship to Individual Patient
Date*

MonthDayYear
Date
Should be Empty: