Consent for Release of Information

Consent for Release of Information

Please complete this form if you would like us to coordinate care with your doctors and therapists. We may send a letter or call your doctor or therapist informing them of your visit and care. You can include any therapists, primary care physicians and other specialists
Patient Name

First NameLast Name
Date of Birth (DOB)

MonthDayYear
I hereby authorize Dr. Dana Reid, LLC to release and/or obtain information from my medical records as described below to the following provider:
Name of Practice
Optional
Name of Provider

First NameLast NameSuffix
Providers Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Providers Phone Number
Format: (000) 000-0000.
Providers Fax Number
OptionalFormat: (000) 000-0000.

The request and authorization applies only to the following information:

Rows	Choose all that apply
Medical History/Physical Exam
Discharge Summary
Psychiatric Reports/Tests
Psychiatric Evaluation
Treatment Recommendations
Laboratory Reports
Summary of Hospitalizations
Psychological Reports
Medications
Course of Treatment
Consultations
Progress Notes
Teachers’ Reports
Social History
Developmental History

The purpose of the release of information is:

Rows	Choose all that apply
Coordination of Care
Continuation of Care

I understand that I can cancel this authorization at any time, except for action that has already been taken.
Signature of Patient or Parent/Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: