Jay H. Berk, Ph.D., Inc.
28001 Chagrin Blvd,, Suite 212
Woodmere, OH 44122
(216) 292-7170 FAX (216) 292-7182

Request and Authorization to Release Records and Information

This request hereby authorizes Jay H. Berk, Ph.D., to obtain and or disclose information regarding:

_______ Myself,

_____________________________________________________________________________
.Your Full Name (Please Print).........................................SSN.............................DOB

_______ My child,.

_____________________________________________________________________________
.Child's Full Name (Please Print).....................................SSN..............................DOB

CHECK ONE OF THE FOLLOWING OPTIONS:

_______ I grant permission to release all pertinent medical, psychological, or legal information pertaining
...............to my child or myself.

________ I grant my permission to release pertinent medical, psychological, or legal information pertaining
.................to my child or myself with the following restrictions:

.................____________________________________________________________________________

TO AND/OR FROM THE FOLLOWING PROFESSIONAL:

_____________________________________________________________________________________
Name..................................................................................................................Title

_____________________________________________________________________________________
Organization (If Needed)

_____________________________________________________________________________________
Street Address....................................................................City.........................................State...........ZIP

_____________________________________________________________________________________
Phone Number................................................................................................FAX Number

.....I voluntarily authorize and request to release/obtain information from my records and fully understand the nature of the records and information released.

I understand and acknowledge that this authorization extends to all or any part of the records designated above which may include documentation of treatment for physical and emotional difficulties, alcohol/drug abuse, and/or HIV/AIDS test results or diagnoses. I expressly consent to the release of the information designated above.

I understand that I may revoke this consent at any time except to the extent that action based on this consent has already occurred. Such revocation must be in written form and dated. This consent will expire automatically when treatment is concluded unless otherwise stated in writing.

____________________________________________________..___________________
Signature of Patient or Parent/Guardian...........................................................Date

____________________________________________________..___________________
Signature of Witness.........................................................................................Date

Please:

1. Download this form to your computer by clicking the tan box below

2. Print a copy.

3. Fill in the information.

4.Mail it to the address at the top of the form or bring it to our office so we may comply with your request to obtain or disclose information.

Thank you