Authorization to Disclose Information

  • Protected Health Information (PHI) includes records and/or reports from the following categories or services: medical services; photographs, films, videos, slides, audio data; emergency services; inpatient hospitalization; outpatient clinical services; laboratory and pathology services; pharmacy and prescription services; medical or psychological history; any and all medical and psychological diagnoses and prognoses; itemized statements; psychological or psychiatric treatment; drug/alcohol treatment; all medical and psychological diagnostic and evaluation information; HIV/AIDS testing; medical or psychological progress notes.

    I hereby authorize:
    Mary Alvarez, Ph.D.
    Licensed Psychologist
    1506 Winding Way #210
    Friendswood, TX 77546
    281 482-0801 281 996-1355 (fax)

    To release the following PHI: psychological records, historical information, applicable correspondence, clinical notations, applicable consultations, educational evaluations, and/or other psychological reports concerning:

  • TO:

  • I also authorize Dr. Alvarez to have telephone discussions of my psychological PHI with the above individual/entity (please initial below).

  • I fully understand this request to release my psychological records, including the nature of the records, their contents, and the consequences and implications of their release. This request is entirely voluntary on my part and I understand that I can revoke this request at any time, except to the extent that action based on this consent has already been taken. This consent will expire one year from the date on which it is signed.

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