HIPAA Authorization to Disclose Mental Health Information
Patient Information
Name
Date of Birth
Address
Phone Number
Recipient of Information
Name/Organization
Address
Phone Number
Information to be Disclosed
Specify information to be disclosed
Purpose of Disclosure
Purpose
Expiration
Expiration Date or Event
Patient Signature
Signature
Date
If Authorized by Personal Representative
Name of Personal Representative
Relationship to Patient
Signature of Personal Representative
Date