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{{ practice_addr }} · {{ practice_phone }} · [email protected]
Form {{ form_no }} Confidential Records Release
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Authorization to Disclose Behavioral Health Records

Confidential · HIPAA 45 CFR §164.508 · Held in trust
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Client InformationThe person whose records are being released
Client name
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Date of birth
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Record / file #
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Address
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Phone
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Release DirectionFrom your current office, to the receiving provider
Released by
Provider / office
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Address
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Phone / fax
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Disclosed to
Receiving provider
{{ to_name }}
Address
{{ to_addr }}
Phone / fax
{{ to_phone }}
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Records to ReleaseCheck the items you authorize Stillwater to share
Treatment summaryCourse of care, goals, outcomes
Progress notesSession notes documenting treatment
Diagnosis / assessmentIntake assessment, diagnoses
Treatment / care planCurrent goals and interventions
Medication recordPsychiatric medication list
Billing / statementsItemized account history
Other (specify):{{ records_other }}
Psychotherapy notes — extra protection Separate consent
Under HIPAA, the therapist's private psychotherapy notes — the personal notes kept separate from your main record — receive special protection and are never released by a general authorization. To include them, you must give your own separate, explicit consent here. You may leave this unchecked and still release everything above.
I specifically authorize the release of psychotherapy (process) notes to the provider named above. Initial
Records dated {{ date_from }}through{{ date_to }} or entire record
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Purpose & Expiration
Purpose of disclosure
Continuing care / transfer of care Coordination with provider Personal use Other
Notes
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This authorization expires
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on or before {{ expire_date }}, or when care has been transferred. If no date is given it expires one year from signing.
Your rights & consent
  1. You may revoke this at any time by writing to Stillwater Counseling. Revoking it stops future disclosures, but does not undo any records already shared in reliance on it.
  2. Your care is not conditioned on signing. Stillwater will not refuse or withhold treatment because you decline to sign this authorization.
  3. Re-disclosure. Once your records reach the receiving provider, they may no longer be protected by HIPAA and could be re-disclosed by that provider.
  4. Copies. You are entitled to a copy of this signed authorization; a copy is as valid as the original.
I have read and understand this authorization, and I am signing it freely and voluntarily to share the records I have marked, with the provider I have named, for the purpose I have stated.
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Signature
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Signature of client
{{ sign_date }}
Date
{{ patient_print }}
Printed name
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Date of birth
Complete only if a personal representative is signing on the client's behalf (legal guardian or health-care power of attorney).
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Signature of personal representative
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Relationship / authority to act
{{ rep_date }}
Date
{{ practice_name_foot }} · Held in confidence Authorization to Disclose Behavioral Health Records · Form {{ form_no_foot }} · Page 1 of 1