Release of Information 2021

1125 West Street, Suite 235 Annapolis, MD 21401-3607

Fax: 443-957-9500 / Office Phone: 667-204-0614
Records Release Authorization

FOR THE RELEASE OF PROTECTED MENTAL HEALTH INFORMATION
By signing this form, confidential psychological and psychiatric information can be released to and/or discussed with the people or agencies listed below unless noted by exclusions or limitations. This form is signed voluntarily and may be revoked at any time. All disclosures made pursuant to this form are valid as long as they were made before the date of revocation.
Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Type a question

MaleFemaleN/A

Section 1
1. I authorize Five-Star Integrated Health Services (Tamia Musgrave) to release and or receive information to/ from the second a party as directed below. Please Check all that apply*

RECEIVE All Medical sources (hospitals, clinic, labs, physicians, psychologist, all other providers, ect.) including mental health, correctional, addiction treatment and VA health care facilities. In addition this includes sharing information for the purposes of Coordination of care.Note any exclusions or limitations here:

Section 2
2. Second Party: Please do NOT put your name in this section. Please put either the name of your Primary care doctor, therapist, individual/parent and/or Facility : *

First Name Last Name Facility Name
Address of the Second Party *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office number of Second Party *
Please enter a valid phone number.
Fax number of second Party
Leave blank if you do not know a valid Fax phone number.
Email of second Party
example@example.com. if known

Section 3
3. Purpose*

I authorize disclosure of all health information, including information relating to medical, pharmacy, mental health, substance abuse, and psychotherapyI authorize only the disclosure of the following information:

Section 4
4. Purpose*

My health information is being disclosed at my request or at the request of my personal representative; orMy health information is being disclosed for the following purpose:

Section 5
5. Note any exclusions or limitations here:
I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is not dependent on my signing this authorization. By signing below, I acknowledge that I have read and understand this document and that I have voluntarily given my provider authorization to disclose my records. I understand that I may revoke this authorization at any time by providing a written notice to my provider, however the revocation will not have an effect on any actions taken prior to the date my revocation is received. I understand that my information may be redisclosed by the authorized person/organization receiving the information, and at that point, the information may no longer be protected under the terms of this agreement. This authorization will expire one year following the date signed unless revoked in writing.
Patient's Signature*

Clear
Patient's signature
Patient Name *

First NameLast Name
Minor Authorization

Authorization is given on this patient’s behalf due to being a minor or unable to sign.
Legal Guardian/Personal Representative Signature:

Clear
Legal Guardian/Personal Representative

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

1125 West Street, Suite 235 Annapolis, MD 21401-3607