Consent for Release of Information

Client Name*
First Last
Client Date of Birth*
MM
DD
YYYY
Client Email*
Authorization*
I authorize Suruchi Saini, MA, LPC, CCTP, BC-TMH, CYT to release the following information or records about me
Behavioral and mental health information
Information Disclosure To / From*
Name of the person or healthcare provider
First Last
Phone*
Email*
Office Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Purpose of Disclosure of Information*
- Continuity of treatment or care
- Planning for treatement or care
- Other
If other, please describe*
Disclosure*
I understand the following: See CFR §164.508(c)(2)(i-iii)
- I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.
- The information released in response to this authorization may be re-disclosed to other parties.
- My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.
Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until two years from date of execution at which time this authorization expires.
I have read and acknowledge
Signature of Patient or Legally Authorized Representative*
First Last
Date*
MM slash DD slash YYYY
Name and Relationship of Legally Authorized Representative to Patient
First Last
Signature*
Electronic Signature Consent*
I consent to signing this document electronically.
Form received on 29/05/2022 from 34.204.174.110