Authorization to Release/Obtain/Communicate Protected Health Information

Authorization to Release/Obtain/Communicate Protected Health Information
Patient Name *

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Patient Date of Birth *

MonthDayYear
Date
I hereby authorize Psych Atlanta to (please only pick one) :*

COMMUNICATE with the following entity/individual in regard to my PHIRELEASE 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 NameLast Name
Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone 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 onlyLabs and imaging studies onlyThe following specific information only that is listed in the box below:
Dates of Service*

Any date of serviceOnly for the following dates of service listed in the box below
Purpose of Disclosure:*

Coordination of careSchool/CollegeFamily Member Access to TreatmentConsult/Second OpinionFMLA/DisabilityInsurance (e.g.: Long Term Care)Transfer of CareLegal (please specify in box below)
Please check the office location where you are normally seen:*

1012 Coggins Place Marietta, GA 30060 Ph. (770) 422-2009 Fax (770) 428-033011755 Pointe Place Suite A-1 Roswell, Ga. 30076 Ph. (770) 667-1264 Fax (770) 667-2238
I understand that:
1. 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.
2. 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.
3. That I am not required to sign this form in order to receive treatment.
4. That there may be a fee for a copy of my medical record.
5. 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 disclosedNo 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 *

Clear
Date Signed*

MonthDayYear
Date
Should be Empty: