Administration Office
N53 W30465 Arrowhead Dr.
Hartland, WI 53029
(262) 367-6488
________________________________________________________________________
Leonard R. Narus, Ph.D
Director
Form #5A
AUTHORIZATION FOR RELEASE OF
CONFIDENTIAL INFORMATION
I ______________________________________, hereby request and
authorize ____________________________________ to release to Arrowhead
Family
Counseling located at the above address the following specific information
from my clinical
record:
____Psychiatric findings
____Psychological findings
____Sociological findings
____Progress reports
____Recommendations
____Final diagnosis/Discharge Summary
____Other (specify)______________________________________________________
that was acquired from___________________through________________.
I am aware
that the disclosure of this information is for the purpose __________________________
_______________________________________________________________________
_______________________________________________________________________.
This authorization may be revoked at any time. This authorization
will be valid for one year
unless an earlier date is specified _________________. I hereby
release the providing
facility from all legal responsibilities or liability that may arise
from this act. I am aware that this
information has been disclosed to you from records whose confidentiality
is protected by
Federal Law. Federal regulations (42 CFR Part 2) prohibit you
from making any further
disclosure of it without the specific written consent of the person
to whom it pertains, or as
otherwise permitted by such regulations. A general authorization
for the release of medical
or other information is not sufficient for this purpose.
Client's Signature ____________________________________ Date:_______________
Person Authorized to consent for client:_______________________________________
Date:________________
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A STATE CERTIFIED MENTAL HEALTH CLINIC