Authorization for Disclosure Form | Dr. Gray and Psychological Associates

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This form when completed and signed by you, provides authorization for Dr. Gray and Psychological Associates to release/receive protected information from your clinical record to/from the person(s) designated within the document.

Email *

Client's Full Name *

Client's Date of Birth: *

YYYY

I authorize DR. GLORI GRAY AND PSYCHOLOGICAL ASSOCIATES to release or receive the following information from the records of the above listed client for services provided during the time period of the last year (or as otherwise relevant)

Please CHECK item(s) to indicate specific authorization *

Evaluation Report

Progress to date

Test Results / Evaluation Report

Symptoms

Behavioral Checklists / Narrative Forms

Treatment Summary

Diagnosis

Treatment Plan

Prognosis

Functional Status

All of the above

Required

THIS INFORMATION SHOULD ONLY BE RELEASED TO OR RECEIVED FROM: *

Please write the NAME, ORGANIZATION NAME (if applicable) and contact information below:

THIS INFORMATION SHOULD ONLY BE RELEASED TO OR RECEIVED FROM:

Dr. Gray and Psychological Associates
360 North Caswell Road | Charlotte, NC | 28204
(o) 704.765.2549
(f) 704.765.4749

I am requesting my clinician to release or receive this information for the following reason(s): *

"At the request of the individual" is all that is required if you are the client and do not desire to state a specific purpose

At the request of the individual

Other:

This authorization shall remain in effect until: *

1 year from now

Other:

You have the right to revoke this authorization, in writing, at any time by sending such written notification to the office address. However, your revocation will not be effective to the extent that Dr. Glori Gray and Psychological Associates has taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.I understand that my therapist generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party.I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPPA Privacy Rule.

Client/Parent's Full Name *

Client/Parent's Signature *

By signing this form electronically, you are agreeing to the terms and conditions stated herein.

Today's Date *

YYYY

A copy of your responses will be emailed to the address you provided.

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