Information Release Form


  • MM slash DD slash YYYY
  • Release Information

  • The information authorized for release may include records that may indicate the presence of communicable or non-communicable disease, including but not limited to diseases such as venereal disease, hepatitis, syphilis, gonorrhea, and the human immunodeficiency virus, also known as acquired immune deficiency syndrome (AIDS)

    NOTICE TO PATIENTS: Information in your medical record that you have or may have a communicable or venereal disease is made confidential by law and cannot be released without your permission except in limited circumstances including release to persons who have had risk exposures, release pursuant to an order of the court or the Department of Health, release among health care providers, or release for statistical or epidemiological purposes. When such information is released, it cannot contain information from which you could be identified unless release of that identifying information is authorized by you, by an order of the court or the Department of Health, or by law

    PROHIBITION ON RE-DISCLOSURE/DRUG/ALCOHOL ABUSE RECORDS: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute alcohol or drug abuse patients

    PSYCHIATRIC RECORDS: Oklahoma State Law (76 OS Section 19) provides that psychological or psychiatric records may not be provided to a patient, their guardians or agents, without consent of the treating physician or practitioner or an order from a courts of competent jurisdiction upon finding that it is in the best interest of the patient.

    I understand that my right to confidentiality under Federal law and regulations does not protect any information about suspected child abuse or neglect. In addition, if there is any reason to suspect that I am in danger of physical or bodily harm, or that anyone else is in danger of physical or bodily harm, that this information is not protected under Federal regulation

    Please be advised that referral sources, especially employers or their designated Employee Assistance Representative, who have an interest in your treatment and ongoing recovery may request information about your current and/or continuing care. This information can only be released with appropriate authorization by you. However, failure to authorize such release may impede a productive relationship with your referral source without implication of liability on the part of Jacquyn Cleary/Cleary Counseling and Consultation, Inc

  • Release of Information

  • I understand this authorization is subject to revocation by me at any time except to the extent that action has already been taken in reliance o it. With this knowledge, I give consent to the release of information in my medical records including any information concerning my identity and I release Jacquyn Cleary/Cleary Counseling and Consultation, Inc. its agents and employees from any liability in connection with the release of the information contained herein

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