I authorize Associates of Springfield Psychological to:
(Please check one)   release information______    obtain information______

(Provide specific information you want disclosed)_________________________________________
__________________________________________________________________________

This information should be released to or requested from (name and address of person(s) to whom the
information is to be released/requested)
__________________________________________________________________________
__________________________________________________________________________

I am requesting the release of this information for the following reasons: ("at the request of the individual" is all
that is required if you are our client and you do not desire to state a specific purpose).
__________________________________________________________________________

This authorization shall remain in effect until (the date listed) or until (fill in an event that relates to the
individual or the purpose of the use or disclosure):
__________________________________________________________________________

You have the right to revoke this authorization, in writing, at any time by sending such written notification to our
office address. However, your revocation will not be effective to the extent that we have taken action in reliance
on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the
insurer has a legal right to contest a claim.

I understand that Associates of Springfield Psychological generally may not condition psychological services
upon my signing an authorization unless the services are provided to me for the purpose of creating health
information for a third party.

I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by
the recipient of your information and no longer protected by the HIPAA Privacy Rule.

______________________           ________________________________      ______________
Print Name of Client                        Signature of Client (age 14 & above)              Date of Birth

______________________           ________________________________      ______________
Signature of Parent/Guardian**     Signature of Parent/Guardian**                         Today's Date

______________________
Witness Signature
** If there is a court order awarding joint legal custody, both parental signatures are required.