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    Release of Information Limitless JanetH

    Uploaded by

    Sydney Maclure

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Release of Information Limitless JanetH

    Uploaded by

    Sydney Maclure
    12 views3 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    12 views3 pages

    Release of Information Limitless JanetH

    Uploaded by

    Sydney Maclure

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    NAME OF THE PROVIDER:

    Janet Howe, ARNP

    PRACTICE ADDRESS:Telehealth Only

    PHONE: (475) 305-0173 FAX: n/a EMAIL: [email protected]

    Release of Information

    I hereby authorize: Janet Howe, ARNP

    To: Release information to: Name: ________________________________

    Obtain information from: Address: _______________________________

    Exchange information with: ______________________________________


    Telephone: ______________________________
    The information requested or authorized for release or exchange pertains to:

    Mental Health

    Mental Health Counseling / Psychotherapy

    Education

    HIV/AIDS

    Sexually transmitted diseases

    Drug or alcohol abuse


    This authorization is valid until ______________. I may cancel this authorization by signing,
    dating, and writing “CANCEL” on this original form or by sending a written, signed and dated
    request to the doctor above indicating my desire to cancel. I understand that once my
    information has been released, the recipient might re-disclose it, my doctor has no control over
    it and privacy laws may no longer protect it. The purpose of this authorization is to improve the
    quality of my mental health evaluation or treatment.

    __________________________________ ___________________

    Patients Name Date of Birth

    __________________________________ ___________________

    Patients Signature Date

    __________________________________ ___________________

    Guardian’s Signature (if patient is a minor) Date

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