AUTHORIZATION TO DISCLOSE / OBTAIN PROTECTED HEALTH INFORMATION

Release of Information Form

AUTHORIZATION TO DISCLOSE / OBTAIN PROTECTED HEALTH INFORMATION
I, Name* , DOB (MM/DD/YYYY)* hereby freely and voluntarily authorize Brownstone Psychiatry to disclose / obtain protected health information to the following entity.
By checking here I authorize Brownstone Psychiatry to

Send Medical Records
By checking here I authorize Brownstone Psychiatry to

Request Medical Records
By checking here I authorize Brownstone Psychiatry to

Have communications with the following entity
By checking here I authorize Brownstone Psychiatry to

All of the Above
Name/Organization *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Fax Number *
Please enter a valid phone number.
The reason for the disclosure is: *
My medical records may include information regarding my diagnosis and treatment of drug, alcohol, Acquired Immunodeficiency Syndrome, (HIV Serology) and Psychiatric Disorders. I understand such information is confidential and is protected by federal law. Those receiving this information will be advised that federal regulations (42 CFR part 2) prohibit their making further disclosure without my written consent or as otherwise permitted by such regulations.
I specifically authorize the release or disclosure of the following designated protected health information (PHI) and/or records, if such information and/or records exits. ( √ Please check all that apply) *

Psychiatric Evaluation History and Physical Billing Information Clinical Notes Neuropsychological Testing Psychosocial Evaluation Treatment Plan Laboratory Results Discharge Summary Entire Record
Other:
I understand that I may refuse to sign this authorization and my refusal will not affect my ability to obtain treatment, payment, enrollment or eligibility for benefits. I may inspect or copy information to be used or disclosed under this authorization. All consents to release the medical record will expire in 180 days from the signed date unless otherwise stated by the patient. I wish to have this consent expire on *

Month Day Year
Date
I understand that having the right to inspect and copy any written information disclosed and the right to revoke this consent at any time by giving written notice to BROWNSTONE PSYCHIATRY.

I UNDERSTAND THAT REQUESTED COPIES WILL BE SUBJECT TO A REASONABLE FEE AS PROVIDED BY STATE LAW. ALL FEES WILL BE ON A PRE-PAY BASIS.

I understand that I may not withdraw authorization for a disclosure that is necessary for the purpose of making payment to the facility for services provided. I understand that federal law and regulations protect the confidentiality of alcohol a drug abuse patient records maintained by BROWNSTONE PSYCHIATRY. Generally, we may not say to a person outside the facility that a patient is in treatment or disclose any information identifying a patient as an alcohol or drug abuse unless:
1. The patient consents in writing by signing an authorization for the disclosure of information
2. The disclosure is allowed by court order
3. The disclosure is made to medical personnel in a medical emergency or to a qualified personnel for research, audit or
4. Program evaluation. (42 CFR, chapter 1 part 2)
Parent/Guardian Signature *

Clear
Date: *

Month Day Year
Date
Witness: *
Should be Empty:

Release of Information Form