Release Form

Please read print and sign.
Fax to: 770 217-6882

I_________________________give permission for ACCC if necessary to obtain information that will help to aid in the therapeutic process.
This information may include diagnosis or prognosis, treatment for, physical illness, substance abuse, Aids or Aids related diagnosis, or HIV test results

To or from the following person or agency
Name of agency______________________________________________
Address_____________________________________________________
City ___________________
State___________________    Zip______________
Phone____________________________


I understand, such information is being is being requested for These purposes:_____________________________________________________
_____________________________________________________________
_____________________________________________________________


I have been told to protect the limited confidentiality of records, my agreement to obtain or release information is necessary and that this permission is limited for the purpose and to the persons listed above, and will be effective during the dates below. I understand that I will be told the name, to whom, and the dates when the information will be sent, and that I may withdraw my permission at any time in writing, I also understand that I may ask to see the information that is to be sent.

____________________________________      ____________________
Signature of client                                                        Date

____________________________________      ____________________
Staff Signature                                                             Date