Mental Health Records HIPAA Authorization

Patient Information

Patient Name Date of Birth Address

Recipient Information

Recipient Name/Organization Recipient Address

Information to be Released

Description of information to be disclosed

Purpose of Disclosure

Purpose

Expiration

This authorization will expire on (date or event):

Authorization & Rights

I understand that I may revoke this authorization at any time by submitting a written request, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed under this authorization could be further disclosed by the recipient and may not be protected by HIPAA.