Name *

First Name

Last Name

Former Name (if applicable)

First Name

Last Name

Date of Birth *

MM

DD

YYYY

I request/authorize Dream Clubhouse Inc to release/obtain all information concerning medical, psychiatric, alcohol & drug abuse, AIDS/HIV and other communicable diseases, test results and/or diagnosis and treatment records. *

To

From

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I am requesting that the specific information noted below be released/obtained: *

Psychiatric Evaluation

Discharge Summary

Social Services Assessments

Medical Tests

Consultations

Other

I am requesting this information to be released/obtained for the following purposes(s): *

Psychosocial Rehabilitation

Continuum of Care

Employment Services

Individual Support

Housing

Other

READ BEFORE SIGNING *

ATTENTION: Once this information has been released pursuant to this Authorization, it may no longer be protected by Federal and/or State law/regulations and may no longer be deemed "Confidential". I state that I have read and fully understand the above "Authorization for Release of Information" and I specifically request its release for the above mentioned purpose, and to be furnished to Dream Clubhouse or to whom I have authorized. I further state that I have executed this Authorization as my one free act and deed. I agree that I have received a signed copy of this Authorization if I chose to do it. I understand that I may revoke this Authorization at any time except to the extent that prior action has been taken in reliance on this Authorization. This Authorization will expire after one year from my signature and date below, if I do not cancel it in writing prior to the expiration date. I understand that if I want to cancel/ revoke this Authorization, I must mail, fax or bring a letter in person stating that I want to cancel this authorization. I understand that I need to mail, fax or bring the letter to the address or fax number listed above. If you are signing on behalf of an individual for whom you are the legal guardian or personal representative, you must attach a certified copy of your appointment as legal guardian or personal representative. If you are signing on behalf of an individual who is deceased, you must attach a certified copy of the person's death certificate.

Agree

Disagree

Signature *

Please sign in agreement

First Name

Last Name

Date

MM

DD

YYYY