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(Required)

Date of Birth(Required)

Email(Required)

Enter Email Confirm Email

Email address to be used for confirmation copy of this document.

Social Security Number

First Person or Agency(Required)

Second Person or Agency

Third Person or Agency

Scope(Required)

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(Required)

I understand that this information is required for a mental health treatment and/or assessment.

This authorization is to permit Dr. Turnbull and the listed parties or agencies to consult with each other regarding my medical and mental health history, current status, and treatment planning.

I understand that this information is required for mental health treatment and/or assessment.

Hidden

Date of Authorization(Required)

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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