Ms. Roseau - Authorization for Release of Healthcare Records

Authorization for Release of Healthcare Records
Is this release for a minor?
Client's Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I hereby request and authorize Diamond Diva Empowerment Foundation to disclose and receive and discuss information from:
Provider's Name:
Provider's Address:
Provider's City/State/Zip:
Information to be disclosed includes copies of:
Explanation of Other:
This authorization will be effective for one year after the date signed, unless cancelled in writing. I understand that the cancellation will have no effect on information released prior to receiving the cancellation. A copy of this authorization is as valid as the original.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I hereby state that my parental rights have not been revoked by a court of law.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Notice to recipient of information: This information has been disclosed to you from confidential records, which are protected by law. Unless you have further authorization, laws may prohibit you from making any further disclosures of this information without the specific written consent of the patient or legal representative.
Should be Empty: