Kathleen Smith, LMFT

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Release of Information Form – Current Clients

Please fill out this form in its entirety to authorize Kathleen Smith, LMFT to access your previous healthcare records.

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Thank you for your response. ✨

Authorization

I authorize the care provider and Headway-managed professional entity from which I receive health care services (collectively, “Provider”), to use and disclose the information below for the following purpose(s) (check all that apply)

Please select any and all patient record items you authorize Kathleen Smith to obtain regarding your current or previous care:(required)

This authorization will expire at midnight one year from the date of my signature below unless otherwise designated in the following fields, or upon the specified event.

Type of Information

I understand that the information to be released may include information regarding biometric information, mental health, genetic testing, substance use disorder, HIV test results, and sexually transmitted infections. (check below if you do not want this information released)

Select applicable areas of information:(required)

Method of delivery

Check all that apply(required)

Purpose of disclosure

Reason(s) for disclosure(required)

Signature & signatories

If you are the patient, please provide your name, the date of your signature, and complete the acknowledgment. If you are not the patient, please provide the patient’s information, then complete the relevant sections below.

By typing my name below, I understand and agree that this typed signature has the same legal force, validity, and effect as a manual signature.

If you are not the patient, please additionally provide your name, confirm which situation applies to the patient, and confirm your legal authority.

By typing my name below, I understand and agree that this typed signature has the same legal force, validity, and effect as a manual signature.