Authorization of Release of Protected Health Information

Patient Information

Name

First

Middle

Last

Date of Birth

Address

City

State/Province

Zip/Postal

Email

Home Phone

Work Phone

Cell Phone

Recipient Information

I do hearby authorize Hollywood Psychology Center and/or its Providers to release/obtain a copy of my mental health records (and/or verbal communications) to/from the person/provider or facility below. (Enter your name as signature)

Name

Phone

Fax

Address

City

State/Province

Zip/Postal

Information to be released/obtained

Patient’s Rights and Privacy

I understand that I may revoke this authorization by providing a written statement to Hollywood Psychology Center, except to the
extent that Hollywood Psychology Center has already completed action on it.
I understand that protected health information disclosed pursuant to this authorization may be re-disclosed to the receipt(s) to other
individuals or organizations that are not subject to privacy protection laws. I also hereby release Hollywood Psychology Center from
all legal responsibilities and liabilities that may arise from the release of such protected health information.
I understand this authorization is valid for the disclosures of the specified protected health information to the recipient above for the
period of six months, and it automatically expires six months after the date this form is executed.

Enter Name as signature of patient or personal representative

Date

Relationship (if personal representative)

Patient is:

Minor

Incompetent

Disabled

Deceased

Legal Authority for Signing

Parent

Legal Guardian

Next of Kin of Deceased