Catherine Zinkel, MSW, LICSW
Flourish Counseling PLLC
Release of Information
Name __________________________________________ Patient date of birth ___ /___ /_______ Previous name(s)_________________________________________________________________
Home address___________________________________________________________________
City___________________________________________State______________Zip code________ phone_____________________________________E-mail address (optional)__________________
I authorize ___________________________to communicate with the person listed below the following types of information:
___ Specific dates/years of treatment______________________________________________________ ___ All health information
OR:
Only release specific health information; please indicate the categories to be released:
___ documentation from a specific program or provider: ___intake evaluation/diagnostic assessment ___individual therapy documentation
___treatment plans
___discharge summaries ___medical evaluations/reports ___ongoing verbal communication
name___________________________________
I am requesting health information be released from ☐ communicated to ☐ or exchanged with ☐: __________________________________________________________________________
clinic/health care provider/person’s name __________________________________________________________________________
Mailing address __________________________________________________________________________
City __________________________________________________________________________
State/ zip code __________________________________________________________________________
Phone (optional)/ fax (optional)
Reason(s) for releasing information: ______patient request
______coordination of care ______discharge and continuation of care ______ legal__________
other ______________________________________________________________________________________
Signature_______________________________________date _______________________
______________________________________________________________________
Relationship to patient (self, parent, guardian, etc.)
This consent will end one year from the date the form is signed unless I indicate an earlier date: Date ___ / ___ / ____