AUTHORIZATION

TO RELEASE MEDICAL/EDUCATIONAL INFORMATION

To: Wellspring Therapy Services

Re: Client Name: Date of Birth: 1. I hereby authorize you to release, disclose and deliver medical and/or educational information described below regarding the above named client to Thembi DePass, MS/CCC-SLP. 2. You are authorized to release all medical and/or educational information from your records on the above named client, except information related to drug or alcohol treatment, mental health treatment, and HIV/AIDS relation information. 3. This authorization may be revoked by the undersigned at any time by given written notice to the party authorized herein. Any disclosure made prior to revocation in reliance upon this authorization shall not constitute a breach of rights of confidentiality of the client. If not earlier revoked, this authorization will automatically expire twelve months from the date of signature. 4. The party named above to receive the information is not authorized to many any further release or disclosure of the information received. This authorization does not authorize release or disclosure of any information except as provided herein. The following notice regarding disclosure of substance abuse information must be included with any such information disclosed pursuant to this authority, if such disclosure is authorized herein. This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. Medical/educational information may be released as provided by this authorization. Signature:____________________________________ Date:_______________________

1123 MD Route 3, Suite 252, Gambrills, MD 21054 240-620-3028