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Counseling Record Release

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All personal health information is considered confidential, and must be kept private. In order to share this type of information with others, a release must be signed by the patient who is able to give consent.  This form contains standard language; however, additional terms and conditions may be added to it, making it fully customizable to fit the needs of the user.  This form should be used to release an individual's personal counseling records.

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									All personal health information is considered confidential, and must be kept private. In
order to share this type of information with others, a release must be signed by the
patient who is able to give consent. This form contains standard language; however,
additional terms and conditions may be added to it, making it fully customizable to fit the
needs of the user. This form should be used to release an individual's personal
counseling records.
                                              WIDGET

   REQUEST/AUTHORIZATION TO RELEASE CONFIDENTIAL RECORDS


I hereby authorize ______________________________Address: __________________
to release information from records about _______________________ DOB: ________
for the following purposes:

___________________________________________________________________

I have had explained to me and fully understand this request/authorization to release
records and information, including the nature of the records, their contents, and the
consequences and implications of their release. This request is entirely voluntary on my
part.

_____________________________                    ______________________ ____________
Signature of Client                                   Printed Name         Date



I witnessed that the person understood the nature of this request/authorization and freely
gave his or her consent.

____________________________                   ______________________ _____________
Signature of Witness                                 Printed Name         Date


     Copy for patient
     Copy to source of records
     Copy for recipient for records




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