Authorization for the Release or Exchange of Information Patient Information Client First and Last Name * First Last DOB Address Phone Number This form, when completed and signed by you, authorizes Tiffany Thomas, LMFT to exchange protected health information (PHI) regarding you/your child with the following person(s) or organization: Name of Individual/Organization Relation to Patient Address Phone Number For the purposes of: Care Coordination unless otherwise specified here: This authorization includes disclosure of information in my chart regarding psychiatric consults and mental illness, developmental disabilities, alcohol or drug treatment, AIDS or AIDS-related illness, sexually transmitted infection, and/or HIV test results, unless I limit the disclosure to exclude the following: Specific Information to be exchanged, obtained, or released: Any Information requested, written or verbal, within reason to maintain client confidence Behavioral/mental health documentation (assessments, measures, screenings, treatment plan, treatment summaries, NOT to include Progress Notes unless separately attached) Psychiatric or Medical Information (medication reports, hospitalizations, medical conditions) Other
