Release of Information Form

1. I, _____________________________________________________ am completing this form to allow the use and sharing of my protected health information.

(print your name and date of birth)
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2. I authorize Behavior Basics Incorporated to disclose my records (Observations, Assessment, Behavior Plan and/or case notes).
2. I authorize Behavior Basics Incorporated to disclose my records (Observations, Assessment, Behavior Plan and/or case notes).
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3. Dates of care for which the information will be disclosed include: From beginning of this treatment episode to present time Or specify the time period for which you are giving Behavior Basics Incorporated the permission to release your records:
3. Dates of care for which the information will be disclosed include:

From beginning of this treatment episode to present time

Or specify the time period for which you are giving Behavior Basics Incorporated the permission to release your records:
From
to
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and
and
4. I authorize Behavior Basics Incorporated to disclose the above noted information to this person &/or organization:
(list below the person(s) and/or the organization(s) that will be receiving your records from Behavior Basics Incorporated; please, be sure to provide complete address and contact information for this “third” party)
Name Street City Zip Code Phone Fax (if known)
5. The information will be used/disclosed for the following purposes (e.g. continuity of care, custody hearing, visitation, etc.):
6. I understand and agree that this Authorization will be valid for one year from this date unless specified otherwise here:

[Note a date or event upon which this Authorization expires. For example, you may choose to have this authorization expire 1 month from today or 6 months from today; or you may request that this authorization expire upon such event as the termination of consultation with Behavior Basics Incorporated, in which case write down in the space above “termination of therapy with Behavior Basics Incorporated.”]
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I understand that after that date or event, no more of this information can be used or released to the person or organization unless I sign a new Authorization like this one.
I understand that after that date or event, no more of this information can be used or released to the person or organization unless I sign a new Authorization like this one.
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7. I understand that I can revoke or cancel this authorization at any time by sending a letter to Behavior Basics Incorporated. If I do this, it will prevent any disclosures after the date it is received but can not change the fact that some information may have been sent or shared before that date.
7. I understand that I can revoke or cancel this authorization at any time by sending a letter to Behavior Basics Incorporated. If I do this, it will prevent any disclosures after the date it is received but can not change the fact that some information may have been sent or shared before that date.
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8. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from the professional or facility listed at number 2, above, nor will it affect my eligibility for benefits.
8. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from the professional or facility listed at number 2, above, nor will it affect my eligibility for benefits.
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9. I understand that I may inspect and have a copy of the health information described in this authorization. There may be a cost for this copy or other services.
9. I understand that I may inspect and have a copy of the health information described in this authorization. There may be a cost for this copy or other services.
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10. I affirm that everything in this form that was not clear to me has been explained and I believe I now understand all of it.
10. I affirm that everything in this form that was not clear to me has been explained and I believe I now understand all of it.
11.
Signature of client or his or her personal representative
Date
MM slash DD slash YYYY

Date
14. I (the client) acknowledge that I received a copy of this completed form:

(please, initial here)
I (the client) have declined the copy of this completed form:

(please, initial here)
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15. Behavior Basics Incorporated, has discussed the issues above with the client and/or his personal representative. My observations of his or her behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent.
15. Behavior Basics Incorporated, has discussed the issues above with the client and/or his personal representative. My observations of his or her behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent.
Signature of professional
Signature of professional
Signature of professional

Signature of professional
Date
MM slash DD slash YYYY

Date
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Email
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Our mission is to sustainably improve the quality of life for each of our clients and their families through education, training and ongoing services.

Solutions 4 Behavior Management

Name	Street	City	Zip Code	Phone	Fax (if known)