"...fostering healing from the inside out"
Phone: (661) 889-4638
Please fill out all required fields before submitting,
• You may end this authorization (permission to use or disclose information) any time by contacting our office
• If you make a request to end this authorization, it will not include information that may have already been used or
disclosed based on your previous permission.
• You will not be required to sign this form as a condition of treatment, payment, enrollment, or eligibility for benefits
• You have a right to a copy of this signed authorization.
• If you choose not to agree with this request, your benefits or services will not be affected.
I hereby authorize the name(s) or entities written below to release verbally or in writing information regarding any medical,
legal/court records, educational records, mental health and/or alcohol/drug abuse diagnosis or treatment recommended or
rendered to the above identified patient. I authorize these agencies to share information by mail, phone, in person, fax
and/or email contact. I understand that these records are protected by Federal and state laws governing the confidentiality
of mental health and substance abuse records, and cannot be disclosed without my consent unless otherwise provided in
the regulations. I also understand that I may revoke this consent at any time and must do so in writing. A request to
revoke this authorization will not affect any actions taken before the provider receives the request.
I hereby authorize ____________________________
to RELEASE/ OBTAIN my protected health information (PHI) to: _____________.
I understand that unless otherwise limited by state or federal regulation and except to the extent that action has been taken
which was based on my consent, I may withdraw this consent at any time. If client is a minor child, I verify that I am the
legal guardian/custodian of this child.
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