Authorization For Release Of Information in Austin, TX

Patient Name*
First Last
Date of birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I authorize Austin Mind and Behavioral Health, its providers and its staff to use, obtain or disclose information about myself or for a minor (under the legal age of 18), for whom I am the legal guardian. The information may be disclosed to the following:
Name
Name of Organization
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Fax Number
Email
I have checked all the information that may be included:
- Psychiatric evaluation
- Psychiatric Progress Notes
- Diagnosis and Treatment
- Substance Use diagnosis and Treatment
- Laboratory Tests or Imaging studies
Purpose of disclosure of information:
1. I fully understand and give this authorization, voluntarily without coercion.
2. I understand that a fax copy or a photocopy of this authorization will be considered as valid as the original.
3. I understand that this authorization is valid for one year from the date of signature.
4. I understand that I can revoke this authorization at any time by notifying Austin Mind and Behavioral Health.
5. I understand that I can request and receive a copy of this form.
With my signature below, I acknowledge that I have read and understand this authorization for release of information.
Signature of patient or Legal Guardian*
Relationship to patient*
Today's Date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Authorization For Release Of Information

Purpose of disclosure of information: