Authorization for Release

This form is for times when Dr. Scheckner may need your permission to speak with other professionals, such as your child’s pediatrician, psychiatrist, teacher, or any other person in order to collaborate and best treat your family.

I, ___(draw your signature into the box below)____, hereby give permission to:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Name/Degree
Address
508 S. Habana Avenue Suite 320-B Tampa, FL 33609
To release information, including academic, medical, medical, psychiatric, and psychological treatment contained in the records of:
Client Name Client Name First Last
Email
Social Security

(do not include hyphens in number)
Name of person, agency, or organization to which information is to be released:
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Specific information to be released:

Specific information to be released: Treatment Summary Academic Records Discharge Summary Psychiatric Records Educational Evaluation Psychosocial History Psychological Evaluation Lab Results Other Other
Date(s) of service

for which information is requested
From From / MM / DD YYYY
To To / MM / DD YYYY
Purpose of release of information:
Section I understand that said information may contain substance abuse and/or client disclosed HIV/AIDS information. This relates shall be in compliance with Federal Regulations (42CFR Part 2, 21 USC Section 290 odd-2), as amended and with all state and local laws, rules, and regulations. Information may not be re-disclosed without further authorization by the client/representative.

This authorization shall remain in effect from the date signed below until:
Expiration date of event Expiration date of event / MM / DD YYYY
I understand that:
- I may revoke this authorization in writing by contacting your office at the above address, attention Privacy
  Officer.
- Information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient
  and no longer be protected by HIPAA.
- I may refuse to sign this authorization and that you will not condition treatment or payment on me providing
  this authorization (except to the extent that the authorization is for research-related treatment, in which case you may refuse to provide that research-related treatment).
- If this line is checked, I understand that you will receive compensation from a third party for the use or disclosure of my information.
- Client Signature
  
  Draw or Type
  
  I understand this is a legal representation of my signature. Clear
  
  Full Name
  
  I understand this is a legal representation of my signature.
- Date Date / MM / DD YYYY
- Parent/Guardian/Foster Parent Signature
  
  Draw or Type
  
  I understand this is a legal representation of my signature. Clear
  
  Full Name
  
  I understand this is a legal representation of my signature.
- Date Date / MM / DD YYYY
- Witness Signature
  
  Draw or Type
  
  I understand this is a legal representation of my signature. Clear
  
  Full Name
  
  I understand this is a legal representation of my signature.
- Date Date / MM / DD YYYY

Authorization for Release

Authorization for Release

To release information, including academic, medical, medical, psychiatric, and psychological treatment contained in the records of:

Name of person, agency, or organization to which information is to be released:

Date(s) of service

I understand that: