Authorization for Release of Psychiatric Medical Records

Patient Information

• Full Name: _________________________ Date of Birth: //___
• Address: _________________________________________________
• Phone: _________________ Email: ___________________________

Records To Be Released From

Provider/Facility Name: ________________________________________ Address: ___________________________________________________ Phone: _________________ Fax: _______________________________

Records To Be Released To

Provider/Facility Name: ________________________________________ Address: ___________________________________________________ Phone: _________________ Fax: _______________________________

Information to be Released (Check all that apply)

□ Complete Mental Health Record □ Psychiatric Evaluation □ Treatment Plans □ Progress Notes □ Medication Records □ Laboratory Results □ Psychological Testing Results □ Discharge Summary □ Other: ___________________________________________________

Purpose of Release

□ Continuing Care □ Personal Records □ Legal Purposes □ Insurance □ Other: ___________________________________________________

Special Authorization

I understand that these records may contain sensitive information. I specifically authorize the release of records relating to (initial all that apply): ___ Substance Use Disorder Treatment ___ HIV/AIDS Information ___ Psychotherapy Notes (requires separate authorization)

Duration

This authorization will expire on: //___ (or 1 year from signing if not specified)

Understanding and Rights

• I understand that I have the right to revoke this authorization at any time
• I understand that information disclosed may be subject to redisclosure
• I understand that I may refuse to sign this authorization
• I understand that refusal to sign will not affect my ability to obtain treatment

Signature: _________________________ Date: //___

If signed by representative: Name: _________________________ Relationship: _____________

For Office Use Only

Received by: _____________ Date: //___ Processed by: ____________ Date: //___