Authorization for the Release of Confidential Information

By completing this form, I authorize Denise O’Doherty LPC MSN to exchange verbal and/or written diagnostic, referral and treatment information about me with the person(s) indicated below.

Your Name*

First Last

Name of party to whom information is being released*

First Last

Specific information to be released regarding:

Check all that apply

Other information to be released*

The purpose of this exchange is to:

Check all that apply

Facilitate Care

Probation / parole requirement

Insurance requirement

Other

Other purposes for this exchange*

I understand that my records and information are highly confidential and are protected under federal, state and local laws, rules and regulations as well as codes of ethics governing the practice of counseling and psychotherapy and cannot be disclosed without my written consent.

I hereby give my written consent to Denise O’Doherty LPC, MSN to disclose the information indicated above for the purposes noted above. I understand that this consent expires 6 months after my last date of service and that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (probation, parole, etc.). I further understand that once I release information to the party listed above that Denise O’Doherty LPC MSN can not ensure the confidentiality of that released material. A photographic copy of this authorization shall be considered as valid as the original.

Signature*

Comments

This field is for validation purposes and should be left unchanged.