[ FORM 54 —Use the top of this page for your letterhead.] Authorization to Release Confidential Information to Family Members Name of patient: Date of birth: Social Security #: I understand that the purpose of this release is to assist with my/this patient’s treatment by improving communication between professional service providers or agencies and the important individual(s) in my/the patient’s life. To further this goal,I authorize this specific service provider,therapist,case manager,or , to release the below-specified information regarding me/the patient to the individual(s) listed below, and to receive information from them. I have been informed of the risks to privacy and limitations on confidentiality of the use of elec-tronic means of information transfer, and I accept these. The information to be disclosed is marked by an × in the boxes below, and any items not to be released have a line drawn through them: q Name of therapist q Name of case manager q
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