1 17 Informed Consent and Release of Information CHFS Authorization to release healthcare informatio 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Client Name, Date of Birth, Email, and Phone Number in the designated fields. This information is crucial for identifying the client.
3. In the section labeled 'The undersigned authorizes The Family Institute (TFI) to', fill in the Name, Relationship, Address, City, State, and Zip Code of the individual or entity receiving the information.
4. Specify the time period for which records are being requested by filling in the start and end dates.
5. Select appropriate categories of information such as Clinician summary, Treatment notes, or Report of progress. Ensure you check all that apply.
6. Indicate the purpose for which this information will be used by selecting from options like Ongoing Care or Treatment Planning.
7. Complete the consent expiration date section. If left blank, it will be valid only on the date received.
8. Ensure signatures are obtained where required: Client (if over 12), Parent/Guardian (if under 18), and Witness. Include dates next to each signature.

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