Apex Therapeutic Services, PLLC
Healing Mind, Body & Spirit
3220 Henderson Drive * Jacksonville, NC 28546 * 910-238-4348*
Release/Exchange of Confidential Information
(Complete separate forms for each request needed)
Client: ______
DOB: ______SS#: ______
I, (Client) ______, hereby give permission to ATS staff to release and/or obtain any and all requested and pertinent information including, but not limited to: employment history, wage verification, school / work or medical information. The information will be used to facilitate collaborative mental health and / or other appropriate supportive services to this Client.
I, (Client) ______, hereby give permission to ______to release and/or obtain any and all requested and pertinent information including, but not limited to: employment history, wage verification, school / work or medical information to ATS. The information will be used to facilitate collaborative mental health and / or other appropriate supportive services to this Client.
Specific information requested/released: ______
____ Reciprocal verbal communication is authorized by Client.
Please consider my consent as valid between starting date: ______and ending date : ______.
Client/Legal Guardian signature: ______Date:______
Witness signature: ______Date:______
ATS requires this form to be completed BY CLIENT to release records to anyone except for the Client. NO records will be released without this form unless it involves mandated reporting of abuse or Apex receives a court order that orders APEX to release records to specified parties. All requestors other than Client will have to complete a request for records form and pay $1 per page. The records can be picked up or mailed within 5 working days.
-Place in Clients file-
Request for Confidential Records of Client
Requestor’s Name: ______
Contact Number: ______
Date: ______
Client’s records requested: ______
Specific Records requested: ______
Reason for requested records: ______
There is a $1 per page charge for released hardcopy records unless requested and provided to Client (in person). Records will be ready to be mailed or picked up in person within 5 working days. Money to be paid before records are released (Cash or Money order only). Records may be FAXED by request.
___Records to be picked up by: Client Requestor
Apex will contact number above.
___Records are to be mailed via of regular mail to: ______
Requestor’s signature/date: ______
To be completed by ATS staff:
Release supported by:
____ Signed Release of Information form (by Client ), dated: ______
____ Court order and…
____ Fees Paid in the amount of $ ______
Records: ___ Mailed ___ Picked up in person ___ Faxed
Date released: ______
Signature/Title of ATS staff: ______
-Place in Clients file-