Form50 - [FORM 50Use the top of this page for your...

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[ FORM 50 —Use the top of this page for your letterhead.] Request/Authorization to Release Confidential Records and Information A. Person or facility: Address: Phone: B. Identifying information about me/the patient Name: Address: Phone: Birthdate: Social Security #: Parent/guardian (if applicable): Address and phone of parent/guardian: C. I hereby authorize the source named above to send, as promptly as possible, the records marked by an × in the boxes below. (The items not to be released have a line drawn through them.) Page numbers are indicated where appro- priate. Written dates (other than those regarding inpatient admission/outpatient treatment) indicate when those records were mailed to the requester. q Inpatient or outpatient treatment records for physical and/or psychological, psychiatric, or emotional illness or drug or alcohol abuse: Date(s) of inpatient admission: Date(s) of outpatient treatment: Other identifying information about the service(s) rendered: q Psychological evaluation(s) or testing records, and behavioral observations or checklists completed by any staff member or by the patient. q Psychiatric evaluations, reports, or treatment notes and summaries. q Treatment plans, recovery plans, aftercare plans. q Admission and discharge summaries. q Social histories, assessments with diagnoses, prog- noses, recommendations, and all similar docu- ments. q Information about how the patient’s condition affects or has affected his or her ability to com- plete tasks, activities of daily living, or ability to work. q
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This note was uploaded on 07/01/2010 for the course COUN 6682 A and taught by Professor All during the Spring '10 term at Walden University.

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Form50 - [FORM 50Use the top of this page for your...

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