Release of Information (If Applicable)

Limited Authorization for Release of Information
I understand that Poppy’s Therapeutic Corner, LLC has an obligation to keep my personal information, identifying information, and my records confidential. I also understand that I can choose to allow Poppy’s Therapeutic Corner, LLC to release some of my personal information to certain individuals or agencies.
I, ___________________________, authorize Poppy’s Therapeutic Corner to share the following specific information with:*
Who To Release Information to:*
Phone Number*

Area CodePhone Number
The information may be shared:*

in personby phoneby faxby mailby e-mail
I understand that electronic mail (e-mail) is not confidential and can be intercepted and read by other people.
What info about me will be shared: (List as specifically as possible, for example: name, dates of service, any documents).*
Why I want my info shared: (purpose) (List as specifically as possible, for example: to receive benefits).*
Please Note: there is a risk that a limited release of information can potentially open up access by others to all of your confidential information held by Poppy’s Therapeutic Corner, LLC.
I understand:
I do not have to sign a release form. I do not have to allow Poppy’s Therapeutic Corner, LLC to share my information. Signing a release form is completely voluntary. That this release is limited to what I write above. If I would like Poppy’s Therapeutic Corner, LLC to release information about me in the future, I will need to sign another written, time-limited release.

Releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from Poppy’s Therapeutic Corner, LLC.

Poppy’s Therapeutic Corner, LLC and I may not be able to control what happens to my information once it has been released to the above person or agency, and that the agency or person getting my information may be required by law or practice to share it with others.
This release expires on:*

MonthDayYear
Date
Time*
I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.
Date:______________ *

MonthDayYear
Date
Signature*

Clear
Date of Birth:*
Should be Empty:

Limited Authorization for Release of Information