HOUSE OF SPEECH
Authorization for Release of Health Information
Client’s Name: ______________________ Date of Birth: ________________
Dates of Service: From ________ (Month/Day/Year) to ________ (Month/Day/Year)
I hereby authorize disclosure of protected health information as follows:
Organization Sending Information: Person/Facility Receiving Information:
House of Speech Name: _____________________________
1049 32nd Street South Address: ___________________________
Birmingham, AL ___________________________________
35205 Phone: ____________________________
Types of Records to be released (please circle):
By signing this release I acknowledge:
1. This information about the client is protected under federal law
2. I may refuse to sign the authorization.
3. I have the right to revoke this authorization in writing.
4. I recognize that the protected health information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of this disclosure and may no longer be protected under federal law.
5. Treatment or payment will not be based on my signing this authorization
6. I will receive a copy of this authorization if I request it.
Signature of Client Date
(Or Guardian if client is a minor)
Relationship of Signatory to Client
Signature of Witness Date