Authorization for Release of Information Form - Upper Bay Counseling - upperbay 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Client’s Name and AKA in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the Date of Birth and last four digits of the Social Security Number. This helps verify the client's identity.
4. Initial all appropriate lines indicating whether you authorize the release or obtain information, including options for verbal communication and ongoing communication.
5. Specify the Method of Disclosure by selecting from options such as Verbal Communication, Photo Copy, or Electronic copy via CD.
6. Indicate any specific information that should not be disclosed in the provided space to protect sensitive data.
7. Initial next to each type of information you wish to disclose, such as Discharge Summary or Psychological Testing.
8. Select the purpose of disclosure by initialing all that apply, ensuring clarity on why this information is being shared.
9. Review your entries carefully before signing and dating at the bottom. If signed by a legal representative, include their relationship to the patient.

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