Authorization to Obtain or Release Protected Health Information

Client Name

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

I hereby authorize Jewish Family Services of Greater Orlando, Inc to

Release records to:
Obtain records from:

Name of Facility or Person

Phone Number

Fax Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Send Records To

Name of Facility or Person

Phone Number

Fax Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

I understand the purpose for allowing the release of information is:

I understand that this consent is revocable upon written notice to the Agency except to the extent that the action by the agency has been taken in reliance of this authorization and this authorization shall remain enforceable for a reasonable time in order to affect the purpose for which it is given. Alcohol and drug abuse information, if present, has been disclosed from records which confidentiality is protected by Federal law. Federal regulations (42CFR, Part II) prohibits making any further disclosures without the specific written authorization of the undersigned, or as other permitted by such regulations.

By signing, I am stating that I am aware that utilizing my mental health records for legal purposes is left up to the interpretation by legal representatives and may or may not be beneficial to my legal case. I hereby release Jewish Family Services of Greater Orlando, Inc. from any and all claims or liabilities resulting from the lease of the above matters in accordance with this counsel.

Client or Legal Guardian Signature

Clear Signature

Date

Agency Representative Signature

Clear Signature

Leave blank

Date

Leave blank

Authorization to Obtain or Release Protected Health Information

Send Records To

About

Contact

Community Services

Volunteer

Events

Resources

Sign Up For Our E-Newsletter!