Release/Request of Information

Client’s name

Date of birth

I hereby authorize: Elisa Elkin-Cleary, LICSW to release to, or request from:

The Following information: Diagnostic and treatment information

This information is needed for the purpose of coordination of care and on-going evaluation by telephone, facsimile, written documentation or meetings if indicated.

I understand that the agency abides by Federal Confidentiality Regulations (42 CFR, Part 2) published July 1, 1975, which protect the confidentiality of my records and that information contained in my record cannot be disclosed without consent unless otherwise provided for in the regulations.
I understand that this directive is subject to revocation at any time upon written request. Otherwise this consent will expire upon one year from date signed.
I herewith release and hold harmless Elisa Elkin-Cleary, LICSW, from any liability for the release of any information provided in accordance with this directive.

Signature

Date