Authorization For Release Of Information in Austin, TX

Patient Name*

First Last

Date of birth*

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:

I fully understand and give this authorization, voluntarily without coercion.
I understand that a fax copy or a photocopy of this authorization will be considered as valid as the original.
I understand that this authorization is valid for one year from the date of signature.
I understand that I can revoke this authorization at any time by notifying Austin Mind and Behavioral Health.
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*

Name

This field is for validation purposes and should be left unchanged.