HIPAA Authorization Form
SHORE TO SHORE PSYCHIATRY an affiliate of PsychMD Healthcare Management Inc.
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Name
First Name
Last Name
Date of Birth
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age
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Indefinitely or until I say otherwise
Allowed Purpose of Disclosure of Information
Indicate the purpose of disclosure (e.g. For coordination of treatment, personal reasons, medical procedure, etc. all acceptable)
Please list other Person(s)/Facility Permitted to see/discuss PHI(Personal Health Information) on your behalf
Who we can share your information with (Ex: Sister, Therapist, Primary Care Doctor etc.)
If you do not want us sharing your information with anyone, please chose this option
Do Not Share Any Health Information without my prior written consent
Type of Medical Information to be disclosed:
All Medical Records
Emergency Records
Financial Records
Evaluation Notes
Medical History & Physical Exams
Prescription Information
Progress Notes
Operation Reports
Laboratory & Pathology Reports
Psychological Tests
Other
Other Information allowed to be disclosed
I give consent to the release of my HIV/AIDS testing information if there is any
I give consent to the release of information pertaining to drugs and alcohol
I give consent to the release of my genetic information and family background information
I give consent to the release of information pertaining to mental health diagnosis or treatment.
Signature of Patient /Subject
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If Patient is a minor or has a legal guardian
*SKIP THIS SECTION IF YOU ARE THE PATIENT*
Name of Parent or Guardian
First Name
Last Name
Relationship to Subject
Signature of Parent/Guardian
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Submit
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