Model Template Agency Release Of Information Form - Manegait
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2ManeGait Information Release Form
Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent
adult, to an individual or group (for example, a doctor or an insurance company). If you are the natural or adoptive
parent or legal guardian, acting on behalf of a minor child, you may complete this form to release only the minor's non-
medical records.
I understand that ManeGait Therapeutic Horsemanship has an obligation to keep personal information, identifying
information, and records confidential. I also understand that I can choose to allow ManeGait to release some personal
information to certain individuals or agencies.
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Name:
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I, ___________________________, authorize ManeGait to share the following specific information with:
Full Name
W
h
o I want to
Name:
W
h
o
have my
Specific Office at Agency:
information:
Phone Number:
The information may be shared:
in person
by phone
by fax
by mail
by e-mail
I understand that electronic mail (e-mail) is not confidential and can be intercepted and read by other people.
W
h
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t
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n
f
o will be
(List as specifically as possible, for example: name, dates of service, any documents).
W
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f
o
shared:
W
h
y I want this info
(List as specifically as possible, for example: to receive benefits).
W
h
y
shared: (purpose)
Please Note: there is a risk that a limited release of information can potentially open up access by others to all of your
confidential information held by ManeGait.
I understand:
That I do not have to sign a release form. I do not have to ManeGait to share information. Signing a release form is
completely voluntary. That this release is limited to what I write above. If I would like ManeGait to release
information in the future, I will need to sign another written, time-limited release.
That releasing information could give another agency or person information about my location and would confirm
that I have been receiving services from ManeGait.
That ManeGait and I may not be able to control what happens to the information once it has been released to the
above person or agency, and that the agency or person getting my information may be required by law or practice to
share it with others.
This release expires on
_____________
__________
Date
Time
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