Consent To Release Form Consent to Release Information - 7/2020 Authorization for use/Disclosure of Protected Health Information This form is required for the release of information and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy standards. I voluntarily consent to authorize to use or disclose my protected health information (PHI) during the term of this authorization to the recipient(s) that I have identified below.*Full Name of Parent/ Guardian I authorize my PHI to be released to the following recipient(s):*Name and address of recipientInformation to be disclosed :I authorize the release of the following PHI: (e.g. Evaluation, FBA, IEP, Treatment Plan)*Please name all the PHI'sPlease choose from one of the following three1. I understand that this authorization will remain in effect from the date of this authorization untilPlease add a specified date if applicable2. I understand that this authorization will remain in effect until the provider fulfills this request 3. I understand that this authorization will remain in effect until the following event occursI understand that signing this form is voluntary and that refusal to sign will not affect the quality of treatment, but may cause interruption in collaboration with other providers and/or insurance authorizations. I understand that I can revoke this authorization, in writing, at any time. The revocation will be effective immediately upon the receipt of the written request.* Refusal to Sign/Right to RevokeI understand that signing this form is voluntary and that refusal to sign will not affect the quality of treatment, but may cause interruption in collaboration with other providers and/or insurance authorizations. I understand that I can revoke this authorization, in writing, at any time. The revocation will be effective immediately upon the receipt of the written request.Parent/Guardian’s Signature*Date MM slash DD slash YYYY Parent/Guardian’s SignatureDate MM slash DD slash YYYY Clients Full Name* First Last
