Authorization to Release Confidential Information

Mitchell Rosen, LMFT

43537 Ridge Park Drive, Suite 100

Temecula, CA 92590

(951) 541-3158
Authorization to Release Confidential Information
I, [Name of Patient]
hereby authorize [name of provider]:
to release confidential information obtained during the course of my treatment to Mitchell Rosen, LMFT [person to which information is to be released]
This Authorization permits the exchange of the following information

Any and All Information Necessary Diagnosis Treatment Plan Prognosis Progress to Date Clinical Test Results Dates of Treatment Patient Records Summery of Treatment Other
If other, please explain:
I authorize the exchange of the information described above for the following purpose(s):
The recipient may use the information described above solely for the following purpose(s):
I understand that I have a right to receive a copy of this authorization. I also understand that any cancellation or modification of this authorization must be in writing.
This Authorization shall remain valid until: (expiration date is one year from date of submission)

Month Day Year
By: [Patient or Patient's Representative]

First Name Last Name
Date
*If signed by other than Patient, please indicate the relationship between Patient and his/her Representative:
Copyright California Association of Marriage and Family Therapists. Rev. 02/04
Case Name
Should be Empty: