Authorization for use and disclosure of protected information


Name of patient: ________________________________________________ Date of birth: ________________,


If patient is a minor (under age 18), this form must be completed and signed by parent or legal guardian. Enter name of person completing this form and relationship to patient if that is the case:


Name of parent/guardian: ________________________________________________ Relationship: ________________


Address of patient/family:






In signing below I authorize the following treatment facility:


Name of treatment facility or clinician _______________________________ ______________


Address: ______________________________________________________________


City _______________________ State ________ Phone __________________


To release the following information (check all that apply)________________________________________________

Psychiatric Records

Psychological Testing

Substance abuse treatment

Records of Psychiatric Hospitalization

Medical Records

Diagnostic & Laboratory Testing

Conversation between clinicians

Conversation with family/friend



Regarding services rendered during the following dates: _______________


To: Dr. Valentine Raiteri, M.D.: 5 W. 19th Street, 9th Floor; New York, NY 10011


The purpose of this disclosure is for treatment and continuity of care.


I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the treatment facility or clinician named above. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurance with the right to contest a claim under my policy.


I understand that this authorization for disclosure is voluntary and that I need not sign this form to ensure healthcare treatment.


This authorization will expire on ______________________ (if no date is entered it will expire in 12 months from the date signed).


Signature of patient, or of parent/legal guardian if patient is a minor:



Signed: _________________________________ Print Name: ________________________ Date __________



Signature of Witness ____________________________ Print Name: ________________________ Date __________