(1) Identify whether the form will be used to disclose, to obtain or to disclose/obtain (share) information and whom you are
authorizing to perform this function.
(2) Check the specific information you wish to disclose/obtain. Check only what is the minimum necessary to fulfill the
purpose of disclosure. Enter a service date – if unknown, indicate “last service date” and only checked information
from last service dates will be released or obtained.
(3) Complete the individual’s name, date of birth, social security number and aliases or a maiden name to help correctly
identify the individual.
(4) Check the purpose or reason why the information needs to be disclosed/obtained.
(5) Circle all manners which the information may be disclosed/obtained. If you wish to restrict any of these, please specify.
If nothing is specified, all manners of release will be considered authorized. (Information will only be faxed if URGENT.)
(6) Complete the name and address of the agency, facility or person to whom you will disclose the information or complete
the name and address of the agency, facility or person from whom you are obtaining the information. If you wish it to
be phoned or faxed, include area code and numbers.
(7) Complete the calendar date (month, day and year) on which this authorization will expire. Information cannot be
disclosed/obtained without a specific date of expiration.
(8) Sensitive information will be released/obtained unless you specifically check an exclusion. If no items are checked
all information within the patient record is subject to disclosure.
(9) Self-explanatory.
(10) Self-explanatory.
(11) Self-explanatory.
NOTE: In accordance with federal and state privacy laws only the following persons shall be entitled to consent in writing to
the inspection, copying and/or the release of the individual’s protected health information.
• The individual if they are 12 years of age or older.
• The parent or guardian of an individual less than 12 years of age (If both parents have co-custody, both
individuals must sign – one on line 13, the other on line 14.)
• The parent or guardian of an individual between the ages of 12 and 17, provided the individual does not object
and has signed the authorization.
• The guardian of a person 18 years of age or older.
• An attorney or guardian ad litem who represents a minor 12 or older provided the court has entered an order
granting this right.
(12) Individual to sign and date here if – age 12 or older.
(13) Parent to sign and date here if –
• Individual is less than 12 years of age or
• If individual is between 12 and 18 and has signed on line 12 or Guardian to sign here if –
• If individual is 18 years of age or older but is legally disabled. You must provide a copy of the Guardianship
court order granting you this right.
Guardian to sign here if –
• If you are a guardian ad litem or attorney representing a minor 12 or older in any judicial or administrative
proceeding. You must provide a copy of the court order granting you this right.
(14) Witness to sign and date here. All authorizations require a witness signature to attest to the identity of the
person entitled to give consent (person signing line 12/13)
Line may be used by a co-custodial parent.
(15) Staff person disclosing/obtaining information signs here. Specific dates when disclosed/obtained shall be documented
in the individual’s clinical record and/or the Disclosure Tracking system.
