1508 PENNSYLVANIA AVENUE WILMINGTON, DELAWARE 19806 PHONE: 302-427-8000 FAX: 833-989-2148
I hereby authorize: Integrated Health & Wellness Services
To: Release information to: Name: Obtain information from: Address: Exchange information with:
The information requested or authorized for release or exchange pertains to:
1. Mental Health 2. Education 3. HIV/AIDS 4. Sexually transmitted diseases 5. Drug or alcohol abuse 6. Other:
This authorization is valid for 90 days from the date below or , whichever is earlier. I may cancel this authorization by signing, dating, and writing “CANCEL” on this original form or by sending a written, signed and dated request to the doctor above indicating my desire to cancel. I understand that once my information has been released, the recipient might re-disclose it, my doctor has no control over it and privacy laws may no longer protect it. The purpose of this authorization is to improve the quality of my mental health evaluation or treatment.
Patients Name
Date of Birth
Patients Signature Date
Guardian’s Signature (if patient is a minor):
