Authorization for Release of Information

This authorization is voluntary and you may refuse to sign it.

 

information relating to:


If you chose "other" please explain here.

If you chose "other" please explain here.

The person or organization authorized to release this information is:


The person or organization authorized to receive this information is:


I understand that protected health information may include information relating to mental health or psychiatric care, treatment for drug or alcohol abuse, and communicable disease, including AIDS or HIV infection, if contained in the medical record.

I understand that Buck Black Therapy, LLC will not make any conditions regarding treatment based on the completion of this authorization.

I understand that I may revoke this authorization at any time by notifying Buck Black Therapy, LLC in writing of my intent to do so. If I do notify Buck Black Therapy, LLC of my intent to revoke this authorization, such revocation will not have any effect on any actions taken by Buck Black Therapy, LLC before the revocation. My notification must be sent to Buck Black, LCSW, 100 Saw Mill Road, Suite 3102, Lafayette, IN 47905.

Unless otherwise revoked, this authorization will expire 180 days from the date this form is signed.

I understand that Buck Black Therapy, LLC will give me a copy of this authorization upon request.

Type your full name for your signature.