Authorization Form for Release of Confidential Information

Patient/Potential Patient Information

Your First Name *

Your Last Name *

Your Relationship to Patient *

Child/Teen's Full Name *

Child/Teen's Date of Birth * +

Street Address *

Address Line 2

City *

State

Zip Code *

Phone Number *

Email Address *

This form grants authorization for the Selective Mutism, Anxiety, & Related Disorders Treatment Center (SMart Center) to acquire and disclose confidential information pertaining to my child with the parties I'm designating below. This may include the following type(s) of confidential information:
• Case Discussion of Patient
• Patient’s Case Notes/Records
• Reports & Handouts
• Appointment Dates

Authorized Parties

I authorize the SMart Center to acquire and disclose information about my child with:

*Note: You may designate a school district name if you are comfortable with us corresponding with anyone from district.

Name:

Relationship to Patient:

Phone Number

Email Address

Name:

Relationship to Patient:

Phone Number

Email Address

Name:

Relationship to Patient:

Phone Number

Email Address

Name:

Relationship to Patient:

Phone Number

Email Address

Name:

Relationship to Patient:

Phone Number

Email Address

Additional Notes/Stipulations

I may revoke this authorization in writing at any time by sending written notification to the SMart Center. My notice will not apply to actions taken by the SMart Center prior to the date of my written request to revoke authorization is received.

Parent/Legal Guardian Signature

By signing below, I understand and agree to the above information. *

clear

Today's Date * +