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
Address
12417 Cedar Road, Suite 23 Cleveland Heights, OH 44106
ellen@ellenrhoffman.com
Call Me
(216) 245-7440