Authorization To Release and/or Obtain Information

I request and authorize Jane M. Greenstein, Ph.D. to release healthcare information for:

Client Name(Required)

First Last

Client Date of Birth(Required)

Authorizing release to the following:

Individual/Agency/School(Required)

Address

Street Address Address Line 2 City State ZIP Code

Phone

Please check all that apply:

verbal communication

written summary

assessment report

other (you will be asked to specify documents and dates below)

I also request and authorize Jane M. Greenstein, Ph.D. to obtain information from the same source.

Information is to be obtained for the purpose of providing assessment services to the client named above. I understand that the information released may include sensitive medical and personal information related to behavior and/or mental health.

REVOCATION AND TIME LIMIT

I understand that this authorization is valid for one time only (for written records) or for one year (for verbal communication), unless canceled in writing by me before the material has been released.

Signature of Client (if 18 or older)

Name of Parent/Guardian

First Last

Signature of Parent/Guardian

Authorization To Release and/or Obtain Information

Authorizing release to the following:

REVOCATION AND TIME LIMIT

Navigation

Contact

Useful Links

Jane Greenstein, Ph.D.