Release of Information template

1. Purpose of Release

• Purpose of ReleaseText

• I authorize the release of the information described below for the purpose stated, and understand it will not be used for any other purpose without further authorization from me.

2. Information to Be Disclosed

• Specific Information / Date RangeText

• The following categories of information may be shared: (tick as applicable) session/treatment notes, assessment reports, correspondence, billing records, or other records as specified below.

3. Recipient of Information

• Recipient Name / OrganizationText
• Recipient Address / ContactText

4. Duration and Right to Revoke

• This authorization is valid for 12 months from the date signed unless a shorter period is stated, and I may revoke it in writing at any time, except to the extent information has already been disclosed in reliance on it.

5. Data Protection

• This release is processed in accordance with the UK GDPR and Data Protection Act 2018. Information disclosed to a third party may no longer be protected by these regulations once received by them.

Client Information

• Full NameText
• Date of BirthDate
• AddressText
• Phone / EmailText

Practitioner / Organization Releasing Information

• Practitioner NameText
• Licence No.Text

Emergency Contact

• Contact NameText
• Relationship / PhoneText

Authorization and Signature

• Client SignatureSignature
• Date signed (client)Date

• By signing below, I authorize the release of the information described above to the named recipient.