Ann Arbor Psych HIPPA Release of Information

Ann Arbor Psych HIPPA Release of Information
Name *

First Name Last Name
Date of Birth

Month Day Year
Date
I authorize Ann Arbor Psych to release information and records to the following people and clinics: *
Clinic:
Therapist Name:
Phone:
Fax:
Email:
(Phone/Fax/Email: any available is helpful if you have it, otherwise we'll try to look it up):

Clinic:
PCP Name:
Phone:
Fax:
Email:

Family/Friend:
Name/Phone/Email:

Family/Friend: 
Name/Phone/Email: Do your best to give us at least one contact point. You can resize the text box and delete what you don't need!
This release of information is reciprocal. This means it releases both Ann Arbor Psych as well as the clinician to communicate about care and send/receive records. *

Yes (strongly needed in most cases) No
Information to be released includes psychiatric/psychological, chemical dependency treatment records and AID, ARC, HIV+ information, if applicable.
Information requested includes: *

Any and all helpful in treatment and coordination of care
The purpose and need for disclosure: *
Continuity of care
Patient may revoke this authorization at any time. If not previously revoked, this consent will expire upon: *

Indefinite
My clinician spoke with me today about Ann Arbor Psych SENDING records and asked me to fill out this form for that purpose.

No Yes
Ann Arbor Psychiatry can send the following records to PCP and Therapist:

Please ask my clinician which notes to send Intake Notes Most recent follow up note from prescriber Notes from other dates indicated below
Is there any additional information about records to be sent?
No additional information
My clinician spoke with me today about Ann Arbor Psych ACQUIRING records from another clincian/clinic and asked me to fill out this form for that purpose.

No Yes
I want Ann Arbor Psych to ACQUIRE records from the following clincian/clinic and have included fax/email/phone number below or above:
The documentation I would like Ann Arbor Psych to acquire

All psychiatric prescriber notes including intake and discharge All clinical notes related to diagnosis of ADHD See below for further information about records to be acquired All emergency room records related to visit on a certain date written in below All clinical notes related to psychiatric hospitalization that took place around date written in below
Any other information about records to be acquired?
No additional information about records to be acquired
Sign your name: *

Clear
Witness Signature if available

Clear
Witness Name if available
Current Date *

Month Day Year
Date
Should be Empty: