Auth to Release/Obtain E-Form

Auth to Release/Obtain Info
Please use the following for correspondnece:

HH @ Lake Ivanhoe Village

1199 N Orange Ave Orlanfo, FL 32804

Email: admin@hhorlando.com

*Email for Coordinating Files Only*

Fax: 407-270-5900
Client Name*

First NameLast Name
The following person(s) and/or organization(s) are authorized to release and/or obtain the administrative & clinical records specified below:
Name (Person / Organization)*
Recipient or Destination
Relationship to Client*
Person / Organization Phone Number*

Area CodePhone Number
Additional Info re: Person(s) / Organization(s) *
Physical Mailing/Billing Address, Preferred Email/Fax/Links, etc
Check all that apply for the following record(s) to be released and/or obtained:*

Demographics/AdministrativeGeneral Clinical or MedicalMental Health/PsychiatricLabs/Drug ScreeningsInsurance/FinancialsAll of the AboveOther
Comments / Notes
Please Also Include Any Secondary Designees Here
Completing this form authorizes HH to send and/or obtain record(s) from those designated above. Pt/Client information is handled confidentially through secure channels/platforms as outlined in Notice of Privacy.
Pt/Client or Guardian Signature*

Clear
To connect with HH administrative personnel:

Call 407-701-4500 (Mainline) or

Complete webform inquiry/request

at hhbrainhealth.com

Designated SMS & Email channels are coordinated by HH once intake/onboarding is complete and Pt/Client has commited to Tx.

Please be advised that any channels without designation are reserved to receive information and/or to distribute files only. Correspondence to such channels will not be considered a valid two-way communication option for Pt/Client.

*Provider Collective Subject to HH Policies*

See HH Mgmt for More re: Corporate/Legal.
Should be Empty:

Auth to Release/Obtain Info