Release of Information

I hereby authorize:              Denise Ibrahim, MS, CRC, LMHC

  To:        Release information to:                   Name:    ______________________________

              Obtain information from:                Address: ______________________________

              Exchange information with:                           ______________________________

                                                                                          ______________________________

                                                                      Telephone: ______________________________

The information requested or authorized for release or exchange pertains to:

☐      Mental Health

☐      Education

☐      HIV/AIDS

☐      Sexually transmitted diseases

☐      Drug or alcohol abuse

☐      Psychiatric evaluation/ discharge summary

☐      Progress notes

☐      Medical test/ studies

☐      Educational testing

This authorization is valid for 90 days from the date below or ___________, whichever is earlier.  I may cancel this authorization by signing, dating, and writing “CANCEL” on this original form or by sending a written, signed and dated request to the doctor above indicating my desire to cancel.  I understand that once my information has been released, the recipient might re-disclose it, my doctor has no control over it and privacy laws may no longer protect it. The purpose of this authorization is for the coordination of care and/or verification of services.

__________________________________                         ___________________

Patients Name                                                             Date of Birth

__________________________________                         ___________________

Patients Signature                                                          Date

__________________________________                          ___________________

Guardian’s Signature (if patient is a minor)                            Date