Declaration Of Restriction For Release Of  Treatment Records And Information


To:  __________________________________________
       Psychotherapist or Counselor

This letter will serve to notify you that I do not authorize you to release originals or copies of my treatment records to anyone, including but not limited to my health insurance or HMO, without my explicit written permission.  Any such a release of my records is a breach of my legal right to confidentiality and privilege under Oregon State Law.  Until otherwise notified by me in writing, this declaration supercedes all other releases, requests or demands made by others. 


Patient/Client Name/


Effective Date: ______________________