Sample Consent for Release of Mental Health Information

CONSENT FOR RELEASE OF INFORMATION						Patients Name (Last, First, M.L)
						DOCS Id. Data of Birth

See Reverse Side /or Instructions			Facility Name Unit/Ward No.
Part I Consent To Release Information
Essence or Nature of Information to be Disclosed
Purpose or Need for Information
From: Name, Address and Title of Person/ Organization/Facility/ Program Disclosing Information			To: Name, Address and Title of Person/Organization/Facility/ Program to Which Disclosure Is To Be Made
A. I Hereby Authorize the One-time Release of the Above Information to the Person/Organization/Facility/ Program Identified Above. I Understand that the Information to be Released is Confidential and Protected from Disclosure. I also Understand that I Have the Right to Cancel My Permission to Release Information at any Time. My Consent to Release Information Will Expire When Acted Upon or 90 Days From this Date, Whichever Occurs First.
Signature of Patient/Person Acting For Patient	Relationship	Date Signed		Signature of Witness			Title		Date Signed

B. I Hereby Authorize the Periodic Release of the Above Information to the Person/Organization/Facility/Program Identified Above as Often as Necessary to Plan For/Provide Care and Treatment. I Understand that the Information to be Released is Confiden? tial and Protected from Disclosure. I also Understand that I Have the Right to Cancel My Permission to Release Information At Any Time. My Consent to Release Information to the Person/Organization/Facility/Program Identified Above Will Expire When I am no lon? ger Receiving Services from such Person/Organization/Facility/Program, or One Year from this Date, Whichever Occurs First
Signature of Patient/Person Acting For Patient	Relationship	Date Signed		Signature of Witness			Title		Date Signed

Record of Information Released
Signature of Staff Person Releasing Information					Title			Date Released

Part II Cancellation/Refusal To Release Information
q I Hereby Cancel My permission to Release Information Indicated in Part I. to the Person/Organization/Facility/ Program whose Name and Address is:		q I Hereby Refuse to Authorize the Release of Information Indicated in Part I. to the Person/Organization/Facility Program whose Name and Address is:
Signature of Patient/Person Acting For Patient	Relationship		Date Signed	Signature of Witness	Title	Date Signed

(Use this space if additional mom is needed to complete any of the items on the reverse side)
-INSTRUCTIONS- 1. Patient Signs A...If the Release of Information is for a Single Event 2. Patient Signs B...If Information is to be Released Periodically during an episode of treatment 3. If the patient is under 18 years of age only the responsible parent, relative or guardian must sign. Exception: if patient is a Voluntary Admission on own application, at least 16 years of age but under 18 years of age only the patient must sign.