Release of Information Form

Release of Information Form

Please complete the below patient information, select whether you are wanting our clinic to recieve records from or send records to another entity, and if their are any specifications.

Austin Neuropsychology, PLLC

711 W 38th Street F-2 Austin, TX 78705

Phone: (512) 637-5841

Fax: (512) 637-5997

David Tucker, Ph.D., ABPP-CN

Melissa Bunner, Ph.D., ABPP-CN

Stephanie Paulos, Ph.D., ABPP-CN

Greg Allen, Ph.D.

Alexandra Clark, Ph.D.

Patient Information
Patient Name*

First NameLast Name
Date of Birth*
I authorize Austin Neuropsychology to __________________________ the person or entity listed below*

OBTAIN RECORDS FROMSEND RECORDS TO
Including information pertaining to:*

Complete RecordNeuropsychology report and scoresConference with the person listed above orally regarding my medical informationBilling Information onlyAcademic RecordsRecords from the following dates:
Release Information

Please enter the entity or persons you would like Austin Neuropsychology to release to or obtain your your records from.
The entity I would like ANP to release/ obtain my records from is:*

A ProviderA friend or family memberAn AttorneyA SchoolOther
The Office, Clinic, or School Name
Their Name

First NameLast Name
Their Phone Number
Please enter a valid phone number.
Their Fax Number
Please enter a valid fax number.
Their email
example@example.com
Their Home or Office Address

Street Address

CityState / Province

Postal / Zip Code
I understand that I may revoke this authorization at any time. This authorization is valid indefinitely until canceled by me, unless otherwise specified. I understand that when Austin Neuropsychology is releasing information to an outside person/entity, this information will be provided within 15 business days from reciept of request and that a fee for preparing and furnishing this infomation may be charged according to ruling set forth by the Texas State Board of Medical Examiners.

Unless specifically restricted, this release encompasses entire record including information pertaining to mental health, drug/alchol use, and HIV/AIDS.
I wish to restrict release of the following types of information:
Name of person completing this form*

First NameLast Name
Patient or Legal Representative Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Release of Information Form

Patient Information

Release Information