Authorization to Release Information

Your privacy is not a formality at Marina Edelman Therapy — it is a foundational commitment. Everything you share within the therapeutic relationship is confidential, and that confidentiality is protected by HIPAA regulations, California state law, and the ethical standards of clinical practice. It is not shared, discussed, or disclosed without your explicit written consent.

There are times, however, when coordinating your care with another provider, sharing records with a referring physician, or communicating with a specific individual or entity is clinically necessary or personally requested. In those situations, the law requires your written authorization before any information can be exchanged — regardless of the purpose or the relationship between the parties involved.

This Release of Information Authorization Form is that consent. It specifies exactly what information may be shared, with whom, for what purpose, and for how long the authorization remains valid. It also protects your right to modify or revoke that authorization at any time, in writing.

Please read each section of this form carefully and completely before signing. Every field matters — the more specific and accurate your responses, the more effectively we can coordinate your care while ensuring your privacy remains fully protected. If you have any questions about what this form covers, why it is being requested, or what your rights are in this process, please reach out before submitting. We are happy to walk you through it.