Authorization for Release of Information Client InformationName* First Last Birthdate* MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Social Security Number*I authorize the use/disclosure of my mental health records and/or information as follows:* I authorize the University Counseling Center to release to the following I authorize the University Counseling Center to obtain information from the following Name*Phone/Fax*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Purpose of use/disclosure of my mental health records and/or information* Health Care Patient Request (I do not wish to be more specific) Involvement in My Care Other Other purpose of use/disclosureInformation to be disclosed* Attendance Summary Reports Substance Use HIV related information Other Other information*Release records according to a date range or all dates* Specific date range All dates/records Beginning of date range* MM slash DD slash YYYY End of date range* MM slash DD slash YYYY I understand that I may revoke this consent at any time by providing written notice. After one year this consent automatically expires or at the following specified date...Consent* I hereby authorize Southern Arkansas University, Counseling Center, to send/receive the above mentioned information. Δ
