About
About Dr. Harris
Choosing Dr. Harris
Therapy
Adults
Kids and Adolescents
Psychotherapy for Men
Tele-Mental Health Services
In-Home Therapy
Download Forms
New Patient
Consent Form
Privacy Practices
Office Policies
Resources
Books by Scott Harris, PhD
FAQs
Articles
Contact
Menu
Scott Harris, PhD
Street Address
City, State, Zip
3104227468
Your Custom Text Here
Scott Harris, PhD
About
About Dr. Harris
Choosing Dr. Harris
Therapy
Adults
Kids and Adolescents
Psychotherapy for Men
Tele-Mental Health Services
In-Home Therapy
Download Forms
New Patient
Consent Form
Privacy Practices
Office Policies
Resources
Books by Scott Harris, PhD
FAQs
Articles
Contact
Release of Information Consent Form
Your Name
First Name
Last Name
I authorize Scott Harris, Ph.D. to send/receive the following (to/from)
Send only
Receive only
Send and receive
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
I understand that I have a right to receive a copy of this authorization. I understand that any cancellation or modification of this authorization must be in writing. I understand that I have the right to revoke this authorization at any time unless Provider has taken action in reliance upon it. And, I also understand that such revocation must be in writing and received by Provider at the address listed above.
Academic Testing Results
Behavior Programs
Case Notes
Intelligence Testing Results
Medical Reports
Personality Profiles
Progress Reports
Psychological Reports
Psychological Testing Results
Service Plans
Summary Reports
Vocational Testing Results
Entire Records
Other (Specify)
The above information will be used for the following purposes
Planning Appropriate Treatment or Program
Continuing Appropriate Treatment or Program
Determining Eligibility for Benefits Program
Case Review
Updating Files
Other (Specify)
Therapist shall not condition treatment upon Patient signing this authorization and Patient has the right to refuse to sign this form. Patient understands that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule, although applicable California law may protect such information.
This authorization shall remain valid until:
eSignature of Client
Date
MM
DD
YYYY
eSignature of Parent/Guardian
Date
MM
DD
YYYY
eSignature of Witness
(if client is unable to sign)
Date
MM
DD
YYYY
eSignature of Person Informing
Date
MM
DD
YYYY
Thank you!