Get Leslie C. Kilpatrick Authorization For Release Of Information 2020-2025

The Leslie C. Kilpatrick Authorization For Release Of Information is a crucial document designed to facilitate the sharing of important client information. This guide provides step-by-step instructions to help users complete the form accurately and efficiently online, ensuring that all necessary information is properly collected and communicated.

Follow the steps to fill out the form effectively.

1. Press the ‘Get Form’ button to access the Authorization For Release Of Information form and open it in your preferred online editor.
2. In the first section, fill in your name as the client in the designated space provided: 'I, _________________________________________, hereby authorize release of the below-identified information.'
3. Select the type of information you wish to be released by checking the appropriate boxes, including treatment records, intake assessment, case notes, or others, followed by specifying any additional information if necessary.
4. Indicate how the information should be shared by selecting one of the options: released from Leslie Kilpatrick to a second party, released to Leslie Kilpatrick from a second party, or exchanged between the two.
5. Provide the details of the second party for information release by filling out the name, address, and phone number in the designated fields.
6. Specify the purpose for the information release by marking one or more checkboxes, such as treatment planning, treatment coordination, or facilitation of referral. You can add any other relevant purpose in the space provided.
7. Review the information for accuracy. Be aware that you can revoke this authorization in writing at any time and that it remains valid for one year unless revoked.
8. Sign and date the form in the designated spaces provided. If applicable, a parent or guardian should also sign if the client is a minor.
9. Finally, ensure that a witness signs and dates the form if required, confirming the completion of the authorization process.

Take the next step to complete and submit your authorization for release of information online today.