Request to Release Confidential Records

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Request/Authorization to Release Confidential Records and Information


I hereby authorize:

Person of facility: ________________________________________________________


Address: ________________________________________________________________


To release information from records concerning ______________________________


Date of Birth ________________;


To the following person or facility: __________________________________________


Address: ________________________________________________________________


For the purpose of: _______________________________________________________


These records concern the time between _______________ and ________________


The information to be disclosed includes the following: _______________________






I have had explained to me and fully understand this request/authorization to release records and information, including the nature of the records, their contents, and the consequences and implications of their release. This request is entirely voluntary on my part. I understand that I may take back this consent at any time within 90 days, except to the extent that action based on this consent has already been taken. This consent will expire automatically after 90 days from the date on which it is signed, or upon fulfillment of the purposes stated above.


 ___________________________  ________________________  ____________________

  Signature of Client                    Printed Name                       Date


___________________________  ________________________  ____________________

 Signature of Parent/Guardian   Printed Name                        Date