Behavioral Health HIPAA Authorization
Patient Name
Date of Birth
Address
Phone Number
Name of Provider or Entity Authorized to Disclose Information
Name of Person or Entity Authorized to Receive Information
Specific Information to be Disclosed
Purpose of Disclosure
Expiration Date or Event
Additional Restrictions or Comments
I understand that:
This authorization is voluntary and treatment is not conditioned on my authorization.
I may revoke this authorization at any time in writing.
Information disclosed pursuant to this authorization may be subject to redisclosure.
Signature of Patient/Representative
Date