Authorization for Release of Information Authorization For Release of Information Authorization For Release of Information Client Name: * Date of Birth * I, _________________________________ * do hereby authorize Bardin Behavioral Health, LLC to release protected health information to and from: * Person/Agency and relationship to client Person/Agency information Person/Agency Address Person/Agency Address Person/Agency Address Person/Agency Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Person/Agency Address Person/Agency Phone Fax I specifically authorize the disclosure of the following health information in the following areas: (check all that apply) * Medical Record Treatment Progress Legal Records Treatment and Service Planning Aftercare Planning & Referrals Demographic Data Insurance/ Financial information OtherOther Signatures Signature Clear Type Name (Parent/ Guardian) Date Signature Clear Type Name (Client or authorized party) Date reCAPTCHA Submit Δ