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