PCF2008.0_Health Care Information Release Accounting Form

Health Care Information Release Accounting Form

Client / Client Name: ___________________________________________________________________ Birth Date: __________________________

SSN: _____ - _____ - _______ Record or Case file Number: _____________________________ Other ID: ___________________________

Please print all information clearly.

* Date of Client	Name of Individual and/or Organization To Whom Client Was Made (Include address, if known)	Description Of How and What Information Was Disclosed			Purpose of Client	Name of Employee Making or Approving Client
* Date of Client		Circle Verbal, Paper or Electronic to indicate how the information was disclosed. Provide a brief description of information disclosed. Indicate if additional documentation or authorization supports this Client.			Purpose of Client	Name of Employee Making or Approving Client
		Verbal Paper Electronic
		Verbal	Paper	Electronic
		Verbal Paper Electronic
		Verbal	Paper	Electronic		12