I authorize Bancroft Behavioral Health, Inc. 5610 Kirkwood Highway Wilmington, DE 19808 Fax: 302-502-3257 Facility Phone: 302-502-3255

To disclose: Psychiatric and Medical Treatment Notes, Labs, Medications, Imaging studies, Opinions, Therapeutic treatment and relative history. Unrestricted communication is authorized between Bancroft Behavioral Health, Inc. and the authorized agency, hospital, attorney or other provider listed below.

*It is our aim to collaborate with everyone involved in your treatment so that we may provide the best treatment*

Please list the name(s) of the person(s) or organization(s) for information exchange:

I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: _________________. If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure. I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.