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 Address

City

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) *

Signature

Type Name (Parent/ Guardian)

Date

Signature

Type Name (Client or authorized party)

Date

reCAPTCHA