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Release of Information
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Email
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Your email
Client Name
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Date of Birth
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Authorization for Release of Information
I hereby authorize Melissa R. Tower, MA, LLP, 3245 Riverwoods Dr. NE Rockford, MI 49341 to release specific information from my record to, and receive referral information from the following:
Name
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Enter provider or organization receiving records.
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Address
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Office / facility mailing address.
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Phone Number
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Office / facility contact.
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The authorization is effective for the following period of time:
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Please enter date range.
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Acknowledgements
The information to be released is to be used only for the purpose of coordination of care.
I understand that I may withdraw this release at any time by notifying the agency holding my records.
I understand that my continued or future treatment by or payment to Melissa R. Tower, MA, LLP, is not conditioned upon my providing or signing this authorization. The information to be released is all of the records specified by description and date and may include information about drug/alcohol usage. Any exceptions are listed below.
Exceptions (optional)
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Disclaimer
Further release of information disclosed by the above authorization is prohibited by the Michigan Mental Health Code (Public Act 258 of 1974 as amended section 748 (3). This means that the released information may not be copied, shared, or released except as consistent with the authorization purposes stated above. This release is in compliance with Title 42 of the Code of Federal Regulations, Part II, which also prohibits re-disclosure. Information concerning HIV status must be specifically requested.
Electronically signed by:
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You acknowledge that entering your name below constitutes as your legal signature and you are entering into a legal agreement.
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