Exchange of Records Form

If you wish to download a PDF file of this form to print and complete by hand, click here.

Patient Information

This form when completed and signed by me, authorizes Dr. and/or his/her staff to / protected health information (PHI) to/from the following individuals:

This authorization shall remain in effect until or no longer than 6 months from the date of signature.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to The Nicholls Group office address, as indicated above. However, my revocation will not be effective to the extent of any action already taken in reliance on the authorization. I understand that my clinician may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party. I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of my information and therefore, it is no longer protected by the HIPAA Privacy Rule.

My name printed below serves as my legal signature.