Release Emergency – Families Matter of RI

and after

AUTHORIZATION TO OBTAIN OR RELEASE CONFIDENTIAL INFORMATION

Client Name *

Date of Birth *

I hereby authorize Families Matter Of RI Counseling and Consultation Services, LLC to:

Obtain from
Release to

Agency/Provider *

Address *

City *

State *

Zip Code *

Phone *

The following information shall be used for the purpose of evaluation and assessment, treatment planning, coordination and consultation with other treatment/service providers. *

Mental health information including psychosocial history/assessments, psych testing, psychiatric and psychological evaluations, treatment plans, discharge summaries.
Treatment of Alcohol/drug use including attendance, toxicology results, diagnosis, discharge summary and other information pertinent to treatment planning
Medical information including but not limited to physical exams, health history, lab results, medication history
Educational information, including Permanent Record Card, academic evaluations, psych and educational testing, educational recommendations and vocational assessments, MDT reports and IEP's.
Social Services information relating to housing, entitlements and other related services needed to address health disparities.

The following information shall be obtained and/ or released via: *

Verbal
Mail/Email
Fax

To cover the following time periods

From: *

To: *

or 30 days after discharge date *

Yes
No

I understand that the information obtained/released under this authorization is protected by laws regarding confidentiality of the State of Rhode Island. I further understand that this authorization will automatically expire one year from the date of signing and that it may be withdrawn by written request at any time. I release Families Matter of RI Counseling and Consultation Services, LLC from any liability that may arise in connection with obtaining and/or releasing this information, provided that said release of information is done substantially in accordance with applicable law. A photocopy of this authorization is as valid as the original. I have read and understand the purpose of this release and am signing this authorization voluntarily. I understand that I may revoke my consent at any time except to the extent that action has been taken in reliance upon it.

Printed name of client *

Signature of client *

Clear Signature

Date *

Printed name of parent/guardian

Signature of parent/guardian

Clear Signature

Date

Printed FMRICC Provider Signature

FMRICC Provider Signature

Clear Signature

Date