Authorization for information release

Your psychological health is an important aspect of your overall health. As part of your health care team, I like to work closely with your physician(s), psychiatrist and other health care practitioners. Please complete a separate form below for each member of your health care team in order to request previous records, release your health care records, or to give me permission to talk with other health care professionals. If you are between 16 and 18, both you, and a parent or legal guardian need to sign the form.

You can also print the form as a PDF

This form when completed and signed by you, authorizes me to release and/or obtain protected
information from your clinical record to the person you designate.

Permission is given to: Lou A. Lichti, Ph.D.
City Park Psychological Services, LLC 209 W Patrick Street, Frederick, MD 21701
301.401.2813 drlou@cityparkpsychological.com

Purpose of Authorization*
- To release information
- To obtain information
Name of Patient*
First Last
Date of Birth*
Month
Day
Year
Information is to be released to and/or obtained from:
Name*
First Name Last Name
Relationship to Client (physician, therapist, family member, other)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Purpose or need for disclosure*
Extent or nature of information to be disclosed*
This is a*
- Single Disclosure
- Continuing Disclosure
I understand that I may revoke this consent at any time. In any event this consent expires automatically as described below.
I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of your information and no long protected by the HIPAA Privacy Rule.
Signature of Patient*
Parent/Guardian Signature (if required)
Signature of clinician
Expiration Date
Month
Day
Year
Email
This field is for validation purposes and should be left unchanged.

Authorization for information release

Information is to be released to and/or obtained from:

Client Downloads

Fee Structure

Dr. Lou Specializes In

Connect