Authorization to Release or Exchange Information
Client Name: Maiden / Other Name:
Date of Birth: Phone Number:
I, , hereby authorize Co-Parenting Solutions, LLC and Jordana Wolfson, LMSW to release information contained in my treatment record (including, if applicable, mental health services, information about substance abuse treatment, and information about HIV infection or AIDS).
Name to Whom Information may be Released:
Name(s) of Person / Agency: Email:
Phone Number: Fax:
Dates of Services to be Released: through
Discription of Information to be Released:
The Purpose and Need for Disclosure of Information:
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to CoParenting Solutions. We may have already released the information based on your original authorization. We will not release any additional information after we receive your revocation. We will not condition treatment or payment based on this authorization or revocation of authorization unless otherwise allowed by law.
Your protected health information will be disclosed as specified in this authorization. This authorization will expire one (1) year from the date of signature, or until we have completed the disclosure(s) you have requested, whichever is longer. This information could be subject to re-disclosure by the recipient and may then no longer be protected.
A copy of this form is as valid as the original.
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Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization to Release or Exchange Information
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