Release of Information Form


Please enter a valid phone number.

Send family program packet and questionnaire (where applicable)

I understand these records may contain information concerning sexually transmitted disease(s), acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), drug abuse, substance abuse, alcoholism, sickle cell anemia, and behavior or mental health services.

I understand that this authorization, except for action already taken, may be revoked by me at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to TPACS. Unless otherwise revoked, this authorization will expire one year from today’s date and must postdate any date of service being requested

This authorization becomes null and void from the date entered in the chart that the chart will be closed.

I understand that TPACS will not condition treatment, payment, enrollment, or eligibility for benefits concerning my health care on whether I sign or refuse to sign this authorization.

I understand that authorizing the disclosure of this health information is voluntary and that disclosure of such information carries with it the potential for unauthorized re-disclosure.

  • Signature of Client/Guardian/Legal Representative ("sign" with mouse or finger)