Authorization to Release Protected Health Information

Fill out the Authorization to Release Protected Health Information form below and submit it to our office once fully complete. If you would rather print a copy of the form, fill it out, and bring it to the office, you can click the button below to download a copy of this form.

"*" indicates required fields

I do hereby authorize Jillian DePaul, Ph.D., to release or disclose protected health information, including opinions, regarding myself or my dependent, to any collateral informant who would have information that may be relevant to the current evaluation. You may choose to include your or your dependent’s (1) primary care physician or pediatrician, (2) therapist (if applicable), (3) prescriber (if applicable), and/or (4) a teacher or school administrator (if applicable) who knows your dependent and could make accurate observations about him or her in the classroom.

Select what information you would like to provide:*

Primary care physician or pediatrician

Therapist

Prescriber

Teacher or school administrator

Primary care physician or pediatrician

Name*

First Last

Email*

Phone*

Address*

Therapist

Name*

First Last

Email*

Phone*

Address*

Prescriber

Name*

First Last

Email*

Phone*

Address*

Teacher or school administrator

Name*

First Last

Email*

Phone*

Address*

Patient Consent

The purpose of the disclosure of this information is to aid in the coordination of my or my dependent’s care. I have been informed that I have the right not to authorize the release or disclosure of the content of my Protected Health Information. I understand that I have the right to revoke this authorization at any time. Should I decide to revoke this authorization, I agree to provide the revocation in writing. The effective date of any revocation will be that date upon which my doctor or therapist receives the revocation.

I relieve Jillian DePaul, Ph.D. of any and all responsibility concerning the confidentiality of my medical and/or psychological records and photocopies released to my physicians/providers, and do hereby waive any and all claims for liability which I might otherwise have for direct or indirect harm or damages caused by the release of records. This authorization will remain in effect, unless revoked, through completion of treatment or evaluation with Jillian DePaul, Ph.D.

Patients Name*

First Last

Date of Birth*

Signature*

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