Authorization To Release Treatment Records {2R}

Restoration Form 2R The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professions Committee on the Professions nd West Wing, 2 Floor 89 Washington Avenue Albany, NY 12234-1000 This form is to be completed ONLY by applicants who answered "YES" to question 10 in Part B of Form 1R Authorization to Release Treatment Records Instructions: If you answered "Yes" to question 10 in part B of the Application for Restoration of a Professional License (Form 1R), you must complete a separate authorization form for each professional practitioner and/or hospital/facility where you have been treated. If additional forms are needed, this form may be photocopied. DO NOT MAIL THIS AUTHORIZATION SEPERATELY. Completed authorizations must be attached to your Application for Restoration of a Professional License (Form 1R). I, _______________________________________________________________________________________________, request and authorize the Print your name here below named licensed professional or practitioner or the below named hospital or facility, to disclose fully to the New York State Education Department and its authorized representatives all information and records relating to the diagnosis, treatment, prognosis made for and/or on my behalf, or service rendered for and/or on my behalf, by the said licensed professional, practitioner, hospital, or facility. I understand that this consent may be withdrawn by me at any time except to the extent that the action has been taken in reliance upon it. In any event, this consent shall expire when the Board of Regents has taken final action on my petition for restoration of my license. I also understand that my disclosure is bound by Title 42 of the Code of Federal Regulations governing the confidentiality of alcohol and drug abuse patient records and that redisclosure of this information to a party other than the one designated above is forbidden without additional written authorization on my part. Name of practitioner: _____________________________________________________________________ License number: ____________________ Or Name of hospital or other facility: ______________________________________________________________________________________________ Signature of petitioner: _________________________________________________________________________ Date: _______ / _______ / _______ mo. day yr. Restoration Form 2R, May 2006 American LegalNet, Inc. www.FormsWorkflow.com