ELECTRONIC MEDICAL RECORD TRANSMISSION RELEASE FORM
Patient's Name
*
First Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date
Person Completing Form:
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Relationship to Patient:
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Information to be disclosed: I authorize the transmission of the following health information from Behaven Kids, LLC to Integrative Psychiatry, LLC for the purpose of continuity of care:
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Health information relating to my medical history, mental or physical condition, and treatment received. This includes Individual Diagnostic Interview, Substance Use Assessment, Psychiatric Evaluation, Therapy Treatment Plan, and Discharge Summary.
Information to be released:
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All dates of service
Between set dates
Start Date
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Month
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Day
Year
Date
End Date
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Month
-
Day
Year
Date
This document is to expire
90 days
from date of signature.
Signature
*
Clear
Date
*
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Month
-
Day
Year
Date
Submit
Should be Empty: