Authorization to Release Health Information

Patient

DOB

I authorize Healing Path Behavioral Health LLC to

disclose to obtain from the following person/organization

Name/Organization

Address/Phone/Fax

Information authorized

Psychiatric records Medication list Treatment plan Labs

Other

Purpose

Expiration/event

I understand I may revoke this authorization in writing to the extent permitted by law, and that disclosures already made in reliance on it may not be reversible.

Patient/Parent/Guardian signature

Date