Nick Holt, LCSW

2001 S. Barrington Ave.

Los Angeles, CA 90025
nickholtlcsw@gmail.com
(310) 439-9144

Release of Confidential Personal Health Care Information

I hereby authorize Nick Holt, LCSW, to disclose records and/or information concerning
_____________________________, date of birth _________________, obtained in
the course of his/her treatment to ______________________.

The disclosure of information authorized herein is required for the following purpose(s):

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________

I further authorize _____________________________________ to release records

and/or information to Nick Holt, LCSW, for the same purposes described above.

I specifically also give permission for the release and exchange of information regarding my HIV
test results and my HIV status information, when applicable.

These records are protected by the California Welfare and Institutions Code Section 5328 and
HIPAA laws. An additional consent must be obtained for any other transfer or disclosure of
information.

This authorization shall be effective __________________________ and is subject to

revocation by the undersigned at any time except to the extent that the action has already been
taken. If not earlier revoked, this consent shall terminate on __________________, not to
exceed one year. I sign this document with full knowledge of its purpose and without duress.

______________________________________________________________
Signature of Patient Date

______________________________________________________________Signa
ture of Therapist Date