Purpose of Release

This form authorizes Matas Mental Health & Wellness Services to disclose medical information as specified below to the designated parties listed in this form. The release of information is intended to facilitate continuity of care, treatment planning, or other specified purposes.

Type of Information to Be Disclosed

I authorize the release of the types of medical information selected below.

I understand that I may revoke this authorization at any time by providing written notice to Matas Mental Health & Wellness Services. However, the revocation will not affect any information disclosed prior to the receipt of the revocation.

Acknowledgment and Consent

I understand that:

I have the right to refuse to sign this form, and my treatment will not be conditioned upon signing it.
Information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA regulations.
I have the right to inspect or receive a copy of the information being disclosed.

Appointment