Release Consent Form

Elizabeth A. Fuller MA, LMFT

971-217-7341

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

Name

Date of Birth

ConsentI authorize Elizabeth A. Fuller to disclose to:I authorize the following person/agency to disclose to Elizabeth A. Fuller:

Relationship to client

Person (Name)

Facility

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Facility Phone

Facility Fax

Items Authorized for Release:Assessment/Treatment SummaryTreatment Plans/ProgressDevelopmental HistoryReferrals/RecommendationsAdmission SummaryMedical InformationDSM 5 DiagnosesDischarge SummaryPhysical/T.B. Test ResultsPresence in FacilityPsych. Evaluations & HistoryEduc. /Emp. /Voc. HistoryBenefits InformationDates of Service for BillingPlease check items to be released.

Other items to release

Purpose of Disclosure of Information:To provide for client’s current needsTo help meet client’s educational/employment/vocational goalsLegal matter: probation and monitoringContinuity of careBillingOther

Means of ReleaseVerbalMailFaxTelephoneComputerHand-carriedEmailCheck all that apply

Records obtained as authorized by this consent for information release will be maintained in accordance with Federal confidentiality regulation (42 CFR, 2), which prohibits further disclosure without written consent of the person to whom it pertains.

Copies of this release are as valid as the original. This release may be revoked in writing at any time except for the extent already relied upon in good faith.

Client Signature

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Witness Signature

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Date of signature

Witness Phone

Autumn to Spring Counseling

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