I authorize (please type "Dr. Cook's Office") to release/obtain the protected health information, including records of mental health services, and/or substance abuse treatment,
Information to be disclosed:
*Unless otherwise revoked, this authorization will expire on the following date or event: ________. If a date or
event is not specified, this authorization will expire one year from my date of signature below.
This authorization is voluntary. I understand that I can refuse to sign this authorization and Dr. Cook’s Office
will not condition my treatment or payment on the signing of this authorization except as allowed under federal
privacy laws for: a) research-related treatment, or b) mental health care provided solely for disclosure to a third
party. I understand that I may revoke this authorization at any time by notifying Dr. Cook’s Office, in writing, of
my revocation. I understand that the revocation will not apply to any information that already was released in
reliance on this authorization. I understand that the health information released under this authorization may be
re-disclosed by the recipient and may no longer be protected under federal privacy regulations.
I hereby release Dr. Cook’s Office from all liability and all claims of any nature whatsoever pertaining to the
disclosure of information, or of any professional opinions, or recommendations as contained in the records
released to or by Dr. Cook’s Office.
(relationship to patient) *complete only if requestor is not patient
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Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: ROI Form
Agree & Sign