Authorization for Release of Confidential Information It’s easy to submit your release online. Just fill out and submit this form. Client Name*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I hereby authorize Karen Chinca, LICSW: to OBTAIN information regarding my care from the below named individual/agency to RELEASE information regarding my care from the below named individual/agency The information may include: Telephone conversations regarding diagnosis and treatment Psychiatric evaluations and discharge summaries Medical records Other Please List:*The Individual / Agency Requesting / Releasing InformationTheir Name*Their Email Their PhoneTheir Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Acknowledgements I have carefully read and understand the above statements and do hereby expressly and voluntarily consent to disclosure of the above information and/or medical records to those persons/agencies named above. This authorization may pertain to information related to alcohol and drug use/addiction. I further release Karen Chinca, LICSW and any other individuals/agencies named from any liability arising from the release of information, provided the information is released in accordance with applicable law. I understand that this directive is subject to revocation at any time upon written request. Otherwise this consent will expire one year from the date signed. I am Signing as:*The ClientA Parent, Guardian, or Personal RepresentativeSignature*Signature of Parent, Guardian, or Personal Representative*If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.):*PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.