Authorization For Release Of Information Form printable pdf download

This UVA Department of Student Health, Counseling and Psychological Services (CAPS)

AUTHORIZATION FOR RELEASE OF INFORMATION

Name ________________________________________________

Date of Birth ___________________________

I hereby authorize the release of below-identified information:

____ Treatment Summary

Intake Assessment

Psychiatric Medication Evaluation

____ Termination Summary

____ Current Issues/Progress

____ Psychiatric Notes

____ All CAPS Records

____ Diagnoses and Dates

____ Therapy Notes

of Treatment

(description of issues discussed)

Other: __________________________________________________________________________________________

This information is to be:

____ released from CAPS to the indicated second party.

____ released to CAPS from the indicated second party.

____ exchanged between CAPS and the indicated second party.

____ I authorize the information to be transmitted by e-mail. Patient’s initials: _________

____ I authorize the information to be transmitted by FAX. Patient's initials: _________

I understand that e-mail is not a secure means of communication and UVa. Counseling and Psychological Services cannot

guarantee that the above-identified information won’t be accessed or read by individuals other than the named recipient.

Second party:

Name:

_______________________________________________________________________

Address: _______________________________________________________________________

_________________________________ e-mail: _____________________________

Phone:

_________________________________ fax:

_____________________________

This information is to be released for the following purpose:

Treatment Planning,

Treatment Coordination,

Facilitation of Referral

____ Clinical/Administrative/Academic. Other: ________________________________________________________

_______________________________________________________________________________________________

I authorize the release of information for the following dates:

All dates of contact

Other (specify date or date range): ______________________________________________________________

This authorization of release pertains only to the above-specified information and to the above-specified parties. I also

understand that I may revoke this authorization at any time in writing except to the extent that CAPS has already taken

actions in reliance on it, and that the authorization will remain valid until revoked or upon expiration of one year from the

date of this signed release.

_________________________________ / _____________________________

_______________________

Patient Signature

Student ID #

Date

Authorization For Release Of Information Form

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