Authorization for Release of Confidential Information

Patient Name*

First NameLast Name

Patient Date of Birth (DOB)*

Date

Email*

example@example.com

I, the above named patient, hereby authorize Family Psychiatry Services and AXIS I Behavioral Center (collectively, Adly Thebaud, MD, PA) to take the following action(s) as it pertains to disclosures to my medical, psychiatric, alcohol or drug diagnosis and treatment information, collectively referred to as Protected Health Information (PHI), contained in my records:

REQUEST & OBTAIN MY PHIRELEASE / DISCLOSE MY PHIEXCHANGE PHI

The above authorization applies only to the following doctor / facility / individual named below:

NAME of Doctor / Facility / Individual

ADDRESS of Doctor / Facility / Individual

PHONE NO. of Doctor / Facility / Individual

FAX NO. of Doctor / Facility / Individual

The information covered by this authorization includes:

The information specified above is requested to be released immediately for the purpose(s) of:

CONTINUATION OF TREATMENTCOORDINATION OF CAREINSURANCEOther

I have the right to receive a copy of this authorization. I understand that this authorization is revocable upon written notice to the office where the original authorization is retained, except to the extent that action has already been taken on this authorization. I understand that information used or disclosed under this authorization may be subject to re-disclosure by the recipient without further protection under HIPAA rules; I understand that I may be charged for copies provided. Incomplete information may cause delay. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. This authorization is valid unless otherwise revoked. I give this consent voluntarily.

Patient Authorization Signature*

DATE:*

DateHourMinutesAM/PM Option

Authorization for Release of Confidential Information

SIGNATURE OF PATIENT PROVIDING AUTHORIZATION