AUTHORIZATION TO RELEASE/EXCHANGE CONFIDENTIAL …
Counseling Center
State University of New York at Buffalo
120 Richmond Quadrangle
Buffalo, NY, 14261-0021
(716) 645-2720
. buffalo.edu
AUTHORIZATION TO RELEASE/EXCHANGE CONFIDENTIAL INFORMATION
This form cannot be used for the re-release of confidential information provided to the Counseling Center by other individuals or agencies. Such requests should be referred to the original individual or agency.
I _______________________________________ authorize the Counseling Center to:
_____ release to:
_____ obtain from:
_____ exchange with:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
the following information pertaining to myself:
_____ treatment summary
_____ history/intake
_____ diagnosis
_____ psychological test results
_____ psychiatric evaluation/medication history
_____ dates of treatment attendance
_____ other (specify) ______________________________
for the purpose of:
_____ evaluation/assessment and/or coordinating treatment efforts
_____ other (specify) ______________________________
This consent will automatically expire one (1) year after the date of my signature as it appears below, or on the following earlier date, condition, or event __________________
_______________________________________. (See back for authorization extension).
I understand I have the right to refuse to sign this form, and that I may revoke my consent at any time (except to the extent that the information has already been released).
__________________________________________ Social Security #:________________
Signature of Client Date OR
Date of Birth:___________________
__________________________________________
Signature of Witness Date
(7/98)
RECORD OF AUTHORIZATION EXTENSIONS
I hereby confirm that I have reviewed this consent form and agree to its extension for an additional:
Check One:
_____ 6 months OR
_____ other (specify) ___________________________
_______________________________________ _________________________________
Client Date Witness Date
Check One:
_____ 6 months OR
_____ other (specify) ___________________________
_______________________________________ _________________________________
Client Date Witness Date
Check One:
_____ 6 months OR
_____ other (specify) ___________________________
_______________________________________ _________________________________
Client Date Witness Date
................
................
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