LifeLens Psychological & Counseling Services Primary Care Physician Communication Consent
PATIENT INFORMATION
(first)
(middle)
(last)
DOB
Primary Care Physician
Street Address (of Physician)
City
Zip
Office Number
Fax Number
I authorize LifeLens Psychological & Counseling Services and my PCP to exchange information regarding my mental health treatment. The information exchanged may include diagnosis medications prescribed, and/or any medical concerns related to my care. The purpose of this disclosure is for coordination of care between LifeLens Psychological & Counseling Services and my physician. This expires upon termination of my treatment with LifeLens Psychological & Counseling Services or my written request.
Please Initial
I do not authorize the release of information to my physician. (Please Initial)
Adult Patient Signature
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If Patient is a minor: Name of Parent / Guardian
If Patient Is A Minor: Parent/Guardian Signature
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
LifeLens
Psychological &
Counseling Services
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