Exchange of Records Form

Exchange of Records Form
Exchange of Records/Release of Information
PATIENT INFORMATION
Patient Full Name*
Date of Birth*

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home/Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Release Records/Request for Records

This form when completed and signed by me, authorizes the following Doctor at The Nicholls Group and/or his/her staff to release/receive/exchange protected health information (PHI) to/from the following individuals:
Your Doctor's Name at The Nicholls Group*
Who is the individual we are allowed to share your information with?

Up to 2 spaces below (#1 and #2) to list the Business, Facility or Individual Name(s) that we are allowed to provide your protected health information (only the information you specify)
Business/Facility or Individual's Name #1*
Business/Facility or Individual's Name #2
Phone Number*
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The following information may be shared (please check all that apply):

Assessment ResultsEvaluation ReportDiagnostic InformationSummary of Therapy SessionsSummary of Clinical FindingsAny and all information necessary
I am requesting that this information be shared for the following reasons:

Treatment PlanningBillingUpdatesOther
This authorization shall remain in effect until the date below or no longer than 6 months from now:
Date*

MonthDayYear
Date
I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to The Nicholls Group office address, as indicated above. However, my revocation will not be effective to the extent of any action already taken in reliance on the authorization. I understand that my clinician may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party. I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of my information and therefore, it is no longer protected by the HIPAA Privacy Rule.

My name printed below serves as my legal signature.
Your Signature*

Clear
Date*

MonthDayYear
Date
Relationship to Patient/Client:*
Put "self" if you are signing your own form
Please verify that you are human*
Should be Empty:

Exchange of Records Form

PATIENT INFORMATION

Who is the individual we are allowed to share your information with?