By signing this form, I allow __________ (insert rehabilitation service provider name or counselor name) to release all documents generated or collected by __________ (insert rehabilitation service provider name or counselor name) in reference to my case to __________ (insert specific name).

This information may be transmitted by facsimile, electronic mail, or regular mail transportation, such as a postal service or courier. If any method is not acceptable, strike through and initial item.

The limits of confidentiality have been discussed with me and I understand them. By signing my name below, I indicate my permission to release the above information and that I understand how it will be used.

This information release is valid for this request only.

RECOMMENDED CITATION

Commission on Rehabilitation Counselor Certification. (2002). Release of Information. Retrieved [date] from, http://www.crccertification.com/pages/30code.html

This release of information form is provided by the Commission on Rehabilitation Counselor Certification (CRCC) as a sample of the content that may be appropriate to include in such a form. CRCC does not endorse this as being appropriate for all settings and circumstances. Forms of this nature must be reviewed for applicability to each particular case and appropriate modifications must be made. Laws in different states and for individual regulatory bodies may have different requirements. Revisions may need to occur to satisfy HIPAA requirements for the transfer of medical records. The client should initial all specific items placed in blanks. Form releases with multiple listings should be avoided.