Client Release Form

Please complete the form below to authorize the release of confidential information.
Fill out all required fields and provide your signature to ensure we can securely process your request.

Release of Confidential Information for Client

Please fill out the following form.

Date

Client's first name

Client's last name

Date of birth

Month

Day

Year

Address

Hereby authorize my doctor

Doctor's name:

Doctor's Phone

Doctor's Fax (if available)

Doctor's Address

To release following confidential information about me:

Physical Exam or Office Visit within the last 12 months that includes-Problem List and Medications.

For the purpose of: to determine eligibility for Adult Foster Care services.

This information will not be given, sold, transferred or relayed to any other person not specified in this consent form, without first obtaining my written consent, which states the need for the proposed new use of this information or the need for its transfer to another person.

Signature

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*The client or guardian has the right to withdraw consent at any time.