Release of Information

AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

This authorization form is required for disclosure of all medical and/or psychotherapy notes.
Information Release for:(Required)
Date
Clinician
to
Address
The following information

Only the minimum information necessary for the appropriate evaluation and treatment of the patient will be released. I understand that once information is disclosed in accordance with this authorization, it may be redisclosed by the recipient(s) and no longer protected by HIPAA Privacy Rules. I further understand that BRBH does not have any ability to prevent subsequent disclosures of my information by the recipient(s

This authorization is specific for this request only and is not a universal authorization. Future requests for disclosure of medical information will require a new and specific authorization.

This authorization goes beyond the consent for Release of Information for purposes of payment, treatment, and Health Care Operations. I understand that I do not have to sign this authorization in order to receive health care benefits.

THIS AUTHORIZATION TO DISCLOSE MAY BE REVOKED BY ME AT ANY TIME EXCEPT TO THE EXTENT THAT INFORMATION HAS ALREADY BEEN RELEASED. Please notify us in writing if you want to revoke this authorization.

This authorization is valid for one year from the date signed below or until

Fill out Patient Forms

Please complete patient forms online before your first appointment.

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