Authorization to Exchange Information First Name Last Name Date of Birth Address Apt, Suite, etc City State Select an Option Alabama Alaska Arizona Arkansas 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 Zip Code Exchange of Information with (Name/Agency) Practice/Agency Address Practice/Agency Address Apt, Suite, etc Practice/Agency City Practice/Agency State Select an Option Alabama Alaska Arizona Arkansas 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 Practice/Agency Zip Code Practice/Agency Phone Number Practice/Agency Fax Number Release Agreement Statement I, freely give consent to Crossroads, Inc. and the informant to exchange the Person’s Name (self if over 16 in MD or legal guardian) below noted information for the purpose of payment, facilitating treatment, and continuity of care for me/for my child. Information Exchange Type Past Treatment Psychological evaluation Discharge summary List of current psychotropic medication and dosages Coordination of services agreement/treatment planning Periodic summary of treatment progress Intake assessment summary Financial Information Current psychiatric diagnosis Verbal exchange Other... If information is required for specific period of time, please specify From Date To Date I understand that my Rehabilitation Coordinator will be supervised and that the supervisor will have access to confidential information. I agree that the Rehabilitation Coordinator’s supervisor may substitute for the PRC in exchange in information. Yes No, I do not wish for CROSSROADS, INC. to exchange information with anyone at this time. This consent to release information is given freely, voluntarily, and without coercion, and be withdrawn by me at any time. Any information I authorize other professionals to release to Crossroads, Inc. will be held strictly confidential and will not be released without my written permission except as permitted by State or Federal law. I understand that I have the right to inspect the record or mental health information on the above-named individual. The information to be disclosed may include information about medical conditions, including HIV/AIDS and substance abuse, which is pertinent and relevant to the facilitation of treatment. This authorization is effective for one year from the date below Email Signature Clear Undo Redo Print Name Relationship to Person Self Legal guardian Foster parent Social worker Other... Signature Clear Undo Redo Submit
