Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorization Notice *

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that: This authorization may include disclosure of information relating to MENTAL HEALTH TREATMENT, and CONFIDENTIAL RELATED INFORMATION. With some exceptions, health information once disclosed may be redisclosed by the recipient. If I am authorizing the release of mental health treatment information, the recipient is prohibited from redisclosing such information or using the disclosed information for any other purpose without my authorization unless permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of mental health information, I may contact the New York State Division of Human Rights at 18883923644. This agency is responsible for protecting my rights. I have the right to revoke this authorization at any time by writing to the provider. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent.

Yes, I agree

Unless previously revoked by me, in writing, the specific information initialed below may be disclosed from the date of 6 months after the cessation of treatment. *

I acknowledge and agree