Authorization to Release/Exchange Confidential Information
I, , hereby authorize:
BlueStone Psychotherapy, PLLC, 17714 Kings Point Dr, Suite B, Cornelius, NC
To communicate with or release information to:
In the following manner:
The information to be used will be limited to the following (check any that apply):
verbal or written communication between professionals dates of treatment attendance diagnosis test results treatment progress clinical and medical documentation other (specify)
I understand that the medical or mental health record to be released may contain information pertaining to psychiatric and/or substance abuse diagnosis and treatment, and may also contain confidential HIV (AIDS) – related information. I understand that the information released by this consent shall not be further released in any way to any other person, entity, or others without additional written consent from me. I understand that I may withdraw this consent at any time prior to the release of the above information. I understand that if I am signing as the parent of a minor or as a guardian, the records release may contain references to myself and my family. I understand that I may revoke this consent to release information at any time prior to the stated expiration. I also understand that any release made between the time I authorized it and then revoked it shall not constitute a breach of my right to confidentiality. This consent, if not withdrawn, will expire one year from the date of signature.
PLEASE NOTE: You must complete and sign the section below even if you are not authorizing communication/release of information.
Your relationship to client:
Leave this empty:
Your legal name
Your email address
Signed by BlueStone Psychotherapy, PLLC
Signed On: May 7, 2023
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization to Release/Exchange Confidential Information
Agree & Sign