Authorization to Release/Obtain/Communicate Protected Health Information
Patient Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Patient Date of Birth
*
-
Month
-
Day
Year
Date
I hereby authorize Psych Atlanta to (please only pick one) :
*
COMMUNICATE with the following entity/individual in regard to my PHI
RELEASE Protected Health information from my medical records to:
OBTAIN Protected Health Information from my medical records from the following:
Name of whom we are communicating with/releasing to/or requesting from:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Fax Number (if requesting that we obtain or send medical records)
*
-
if records are not being faxed, enter (555) 555-5555
Please check the information to be released in either verbal or written form.
*
All medical records including diagnostic evaluation, progress notes, phone calls, labs, consults and neuroimaging reports. This does not include any records designated as psychotherapy notes.
Medication records only
Labs and imaging studies only
The following specific information only that is listed in the box below:
Other
Dates of Service
*
Any date of service
Only for the following dates of service listed in the box below
Other
Purpose of Disclosure:
*
Coordination of care
School/College
Family Member Access to Treatment
Consult/Second Opinion
FMLA/Disability
Insurance (e.g.: Long Term Care)
Transfer of Care
Legal (please specify in box below)
Other
Please check the office location where you are normally seen:
*
1012 Coggins Place Marietta, GA 30060 Ph. (770) 422-2009 Fax (770) 428-0330
11755 Pointe Place Suite A-1 Roswell, Ga. 30076 Ph. (770) 667-1264 Fax (770) 667-2238
I understand that:
I may revoke this authorization at any time by notifying the clinican or organizational provider in writing, and my revocation will be effective on the date notified except to the extent action has already been taken in reliance upon it.
Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy regulations.
That I am not required to sign this form in order to receive treatment.
That there may be a fee for a copy of my medical record.
That information to be released or obtained may include mental health information in accordance with CGS 52-146(d), substance abuse treatment informaiton in accordance with 42 CFR 2.1-2.67, and/or HIV/AIDS related information inaccordance with CGS19a-585(a), except as indicated below:
The following should not be disclosed:
No Substance Abuse treatment should be disclosed
No HIV/AIDS information should be disclosed
I understand that this authorization will expire one year after I have signed this form or as specified here: (length of time)
*
Signed
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: