Authorization to Release Information

Authorization to release information (Portland)

AUTHORIZATION TO RELEASE INFORMATION

This form allows you to give permission for Azizeh E, Rezayian, MA, LMFT, to share specific information from your mental health treatment with a person or organization you name.

You are not required to sign this form. Signing is voluntary and will not affect your care.

First Name

Last Name

Provider Name

Consulting Practitioner Name

Consulting Practitioner Phone

Briefly explain why you are authorizing the release of this information (e.g., coordination of care, legal purposes, personal request).

Check all that apply:

Clinical Evaluation

Clinical Treatment

Such disclosure shall be limited to the following specific types of information:

Clinical Observations, diagnoses, treatment goals, information related to my treatment of this patient.

Please read and confirm each statement:

I understand that I have the right to receive a copy of this authorization.

I understand that any cancellation or modification must be in writing.

I understand that I can revoke this authorization at any time unless the provider has already relied on it.

I understand that revocation must be submitted in writing to Azizeh E. Rezayian, MA, LMFT.

I understand that signing this authorization is not a condition for treatment.

I understand that disclosed information may no longer be protected under HIPAA, but may still be protected under State law.

To sign this document, write your name in the field below.

Date

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