PHI Release 2021 | Behavioral Therapy

Client Name

Treatment Dates

SSN#

I Authorize

Name of client or client’s legally responsible person

Agency or person authorized to use/disclose the information

To use or disclose PHI of the client above to: (your service provider, physician, school, daycare, etc.)

Other (specify)

Purpose of use and disclosure

Signature of Client

Signature of Legally Responsible person

Signature of Witness

If you would rather print this form and return to us in person or by mail, click on the button below labeled "Printable Forms".

Our address is. Tri-Cities Behavioral Therapy 321 West Walnut Street Box #2 Johnson City, Tennessee 37604

Printable Forms

Click (Submit) to finish the form. If you can not continue make sure all required fields with an ( * ) have been filled out. Any missed fields will be highlighted in red to make it easier in finding them.

Cancel and return to Intake Forms

I Authorize

Authorization to Release and Obtain Protected Health Information (PHI)