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Release of Schedule Information
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1
Patient Name
*
This field is required.
First Name
Last Name
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2
Date of Birth
*
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Month
Day
Year
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3
Name of Authorized Person
*
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The name of the person that you are authorizing to receive or communicate schedule information.
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4
Authorized Person's Phone Number
Area Code
Phone Number
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5
Would you like Grand Island Mental Health to release schedule details to the person listed above?
*
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This could include past appointment dates, future appointment dates, creating an appointment, and/or cancelling an appointment.
YES
NO
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6
This consent is active for duration of treatment or until terminated by client.
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7
Was this a verbal release completed by a staff member of Grand Island Mental Health?
*
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YES
NO
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8
Signature of Patient/Guardian
Clear
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9
Name of staff member who took the verbal authorization:
Chantal Kohl
Mikki Lemmer
Amanda Porter
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10
Today's Date
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Date
Month
Day
Year
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