Patient Release Form - insytepsychiatric.com

2 Auer Ct Suites E and F,
East Brunswick,
NJ 08816

Monday-Friday: 8am-8pm
Phone: 732-515-5089
Fax: 732-561-4702

Client’s Name

Date of Birth

I, request and authorize Lydia Keise to release/receive healthcare information for the purposes of treatment.

Information may be released to

Information may be obtained from

Name of Individual

Relationship to client

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Fax Number

(Additional Release form required for more than one individual)

This request and authorization applies to (check all applicable)

All Healthcare InformationToxicology Test ResultsSubstance Abuse Evaluation HistoryOther

Other: (Please specifically define information to be released)

***Pursuant to NJAC 13:35 6.5, Insyte Psychiatric reserves the right to charge $1.00 per page per medical record reproduction, or $100.00 for the entire record, whichever is less.

I understand that the exchange of information as requested above. I also understand that this release will remain in effect until .

I understand that I may revoke this authorization in writing, which will take effect on the date it is received, except to the extent that Insyte Psychiatric has already taken action in reliance upon my authorization, or as a condition of obtaining insurance coverage or required by applicable laws or regulations as set forth by InsytePsychiatric’s Notice of Privacy Practices.

I understand that if the above named person or entity is not a heath care provider or part of a health plan covered by federal privacy regulations and this form authorizes the release of my health information, my health information may be re-disclosed by the person or entity I have named above and will no longer be protected by these regulations. However, the person or entity above may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.

I understand that if I refuse to sign this form, Insyte Psychiatric will not disclose my information to the person or entity named above, unless otherwise required by law. Furthermore, I understand that Insyte Psychiatric will not condition any treatment or services on my signing this form.

Signature

Date