Release Form

Confidential Release of Information Form

Instructions: This form is to be completed by a client (or former client) requesting a release of information. Given the nature of services provided, a call may be made to the client (or former client) to verify information and to explain limits of information shared. This form can be faxed or mailed with appropriate letter or accompanying phone call explaining request.

Confidential Release of Information

Please Enter Your Name

First Name

Last Name

Please Enter Your Date of Birth

MM

DD

YYYY

By checking this box you are hereby authorizing Anj or Tim Shutt at True Life Exchange to disclose/discuss specific health information from the records of the above named client to:

Please add name of allowed personnel

First Name

Last Name

Please add address of allowed personnel

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please add phone number of allowed personnel

(###)

###

####

Please add specific information to be disclosed

Please add today's date

MM

DD

YYYY

By checking this box I hereby understand that I'm giving my signature as consent for True Life Exchange to disclose/discuss the submitted information. I understand that Anj or Tim Shutt at True Life Exchange are in no way legally responsible for the information I have submitted.

By checking this box I understand that I may only revoke this form by notifying, in writing, the person, department or office authorized by this form to release information. I further understand that, after this date, I will need to sign a new release form should I wish to continue to authorize the release of information.

By checking this box I understand that this consent is valid until one year from the date of the signature, unless I specify an alternative expiration date or condition. This form provides and indefinite disclosure for information released in regard to financial transactions. I also understand that I may revoke this authorization at any time. I further understand that any action taken on this authorization prior to the rescinded date is legal and binding. I understand that my information may not be protected from re-disclosure by the requester of the information; however, if this information is protect by the Federal Substance Abuse Confidentiality Regulations, the recipient may not re-disclose such information with my further written authorization unless otherwise provided for by state or federal law. I understand that if my record contains information relating to HIV infection, AIDS or AIDS-related conditions, alcohol abuse, drug abuse, psychological or psychiatric conditions, or genetic testing this disclosure will include that information. I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services, or my eligibility for benefits. However, if a service is requested by a non-treatment provider (e.g., insurance company) for the sole purpose of creating health information (e.g., physical exam), service may be denied if authorization is not given. If treatment is research-related, treatment may be denied if authorization is not given. I further understand that I may request a copy of this signed authorization.