Instructions for Authorization For Release of Information Form

Incomplete or improperly filled out forms may be returned.

  • Put your name and date of birth in the appropriate blanks.
  • Where it says, “I hereby authorize the Counseling and Psychiatric Service at Georgetown University to exchange protected health information below with these parties:” enter the name and contact information of the individual with whom you would like CAPS to communicate ro check of the Georgetown office.

Check the relevant boxes where it says “I authorize the disclosure of the following types of clinical records created during the period from first contact with CAPS through the date of signature below, unless another time period is specified:”

  1. All records
  2. Attendance (appointments scheduled and met; dates of service)
  3. Treatment plan
  4. Safety concerns (level of danger to self or others)
  5. Treatment summary
  6. Alcohol and other drug use
  7. Academic related issues
  8. Billing records
  9. Written mental health records
  10. Other:

Check the relevant boxes where it says: “The purpose of the Requested Use or Disclosure is:”

  1. At the request of the patient
  2. For continuity of care
  3. For coordination of care
  4. To address academic concerns
  5. For medical leave of absence or assessment for return
  6. Other:
  • You do not have to fill out the following blank unless you want to:

“Expiration Date: This authorization automatically expires 365 days from today’s date, unless an earlier date or event is specified:

  • Sign and date the form.
  • Have a witness sign and date the form.