Authorization to Release Protected Healthcare Information

This form requests and authorizes J. Gregory Turnbull, Psy.D., J.D. and the named persons and/or entities
to disclose, release, exchange, and use my protected healthcare information.

Client Name
Prefix First Middle Last Suffix
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number
First Person or Agency*
Second Person or Agency
Third Person or Agency
Scope*
- Select All
- Protected Healthcare information relating to diagnosis and treatment
- Reports and records concerning any drug and/or alcohol abuse care assessment and/or treatment, psychiatric and psychological assessment, counseling and/or treatment, and any infection, human immunodeficiency virus (HIV) infection, AIDS related complex (ARC), or acquired immune deficiency syndrome (AIDS), or any other infectious and communicable disease or condition.
Consent*
I understand that this information is required for a mental health treatment and/or assessment.
Date of Authorization*
Date Format: MM slash DD slash YYYY

This authorization expires after one year or at any earlier time you choose by giving notice to Dr. Turnbull,  except to the extent that action has been taken in reliance on the authorization by any of the parties listed.
Name
This field is for validation purposes and should be left unchanged.

J. Gregory Turnbull, Psy.D., J.D.

Psychologist in private practice in Kailua, Hawaii

Authorization to Release Protected Healthcare Information

Authorization to Release Protected Healthcare Information

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