Date:*
Patient Name:*
Your email*
Patient DOB:
Parent or Guardian Name:
I, authorize Tonya Rowe, LCSW with Hope Restored Services to:
Release:
Obtain from:
Exchange with:
My protected health information indicated below:
Written/electronic records: Initial AssessmentTreatment Plan,Treatment Summary
Verbal communication between Tonya Rowe and
For the purpose of*: continuation of careevaluation/assessment and/or coordinating treatment effortsother
Please specify:
Hope Restored Services is releasing a copy of patient’s records directly to the patient. Hope Restored Services is not liable for the confidentiality of the copies of these records, once they are released to the patient or authorized patient representative. Type your initials
This consent will expire one (1) year after the date of my signature.
I authorize the above disclosure and have had an opportunity to review this form and ask any questions.
Patient Signature/Parent or Guardian Signature:*
By checking the box, I agree that the above information is accurate and true.
