Consent for Release of Information — Online Form

Online Form

Clients of Therapeutic Services Agency, Inc. (TSA) — or their legally authorized representatives — submit this form to authorize TSA to release protected health information to, or receive it from, another individual, agency, or clinic.

Prefer paper? Download the PDF version All forms

Client Information

Name

Date of Birth

Address

Phone

City

State

Zip

I authorize TSA Inc. to

If you want to allow Therapeutic Services Agency, INC (TSA) to both share and receive information, please mark both choices.

Agency/Name

You may only enter one individual, entity, or clinic per each form.

Address

Phone

City

State

Zip

Fax

Attn (optional)

Information to be released

Any and all records

If you select “any and all” records, your entire record will be provided for a specific visit date or all dates.

Approximate dates of service (optional)

From

Please specify information to be exchanged

Other

Release Instructions

Information will be released by the following, unless crossed off

Health information includes both written and oral information. If you do not want to give permission for verbal communication to occur, indicate that here.

Purpose of Release

Other

This authorization lasts for one year after the date you sign it unless you enter a different date or expiration here

Examples of an event are: “60 days after completion of services” or “once health information is sent”.

I understand that

I may revoke this authorization in writing at any time, unless action has already been taken on it. Once information is disclosed it may no longer be protected by federal or state privacy rules and therefore may be re-disclosed by the recipient of the information without protections. There may be a charge associated with this release of information request. Signing this authorization is not required in order for me to receive treatment except as indicated in any privacy practice notices I have received. My records may contain information regarding my mental health, substance use or dependency, and may contain confidential HIV/AIDS related information. I further understand that by signing below, I am authorizing the release or exchange of these records to the parties identified. A photocopy/fax of this authorization will be treated in the same way as an original.

Your signature indicates that you have read and understand this form, and authorize release of your information as described above.

Patient’s Signature

Typing your name here acts as your electronic signature.

Date

OR legally authorized representative’s signature

Typing your name here acts as your electronic signature.

Date

Relationship to Patient (if applicable)

Download the PDF instead

Submissions are transmitted over an encrypted connection and stored securely for the TSA intake team. Typing your name in a signature field constitutes your electronic signature.