RELEASE OF INFORMATION - STAY AND TALK

SUBJECT: Release of Information – [Your Full Name]

Full Name:

Date of Birth:

Phone Number:

I, [Your Full Name], authorize Tyler Zenz, MA, LAC at Stay and Talk to release and/or obtain the following information:

Verbal Communication (Yes/No):

Written Records (Yes/No):

Comprehensive Assessment (Yes/No): 

Other:

This information may be shared with: 

Name/Organization: 

Phone Number or Email: 

Relationship to You (e.g., treatment provider, friend, caseworker): 

Purpose of Release: 

I understand that:

- I can revoke this authorization at any time in writing.

- This authorization will expire one year from today, unless I specify an earlier date below.

- I have the right to refuse to sign this form, and services will not be denied solely because I choose not to release information.

- Once the information is released, it may not be protected under HIPAA if shared with someone outside of a healthcare setting.

Expiration Date (if different than one year):

Signature (Typed Name): 

Date: