Authorization for the Release of Information

Your Name Your Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Panther ID Number:
Phone Phone - ### - ### ####
Email
FIU Email
This will authorize

Put N/A if it doesn't apply
and/or designee of Counseling & Psychological Services to release to and/or receive from, general medical, as well as psychiatric/psychological, information from my record with the following person or entity (please add full name, title, address, phone number, email, fax number, and any other information regarding the person you want information to be released to/from in this space):

Put N/A if it doesn't apply
The Specific Information Requested is:

The Specific Information Requested is: Treatment Summary Physical Psychological Testing Acknowledgement of Treatment History Neuropsychological Testing Psychiatric Evaluation/Consultation Verbal Report Other (specify): Other (specify):
For the purpose of:

For the purpose of: Evaluation & Continuing Treatment Other Other
I understand that I have the right to refuse to sign this authorization, and that the facility named above as the releasing agency is released from all legal liability that may arise from the release of the information requested.

I further understand that I am authorizing the release of information from records whose confidentiality and privileged status is protected by State and Federal Law. I hereby release Counseling and Psychological Services of all liability that may arise from the use/misuse of these records by the recipient.
This for authorization is for a

This for authorization is for a Single a continuing disclosure, which is valid for ninety (90) days after the date of my signature as it appears below, or a continuing disclosure, which is valid for (365) days after the date of my signature as it appears below.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date: Date: / MM / DD YYYY
Signature of empowered representative:
(Parent or guardian if individual is a minor)

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY