PBS Psychiatry Consent for Release of Information

Philadephia Better Stories Psychiatry Consent for Release of Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
I do hereby consent and authorize Philadelphia Better Stories Psychiatry (PBS Psychiatry) to release any information pertaining to me to the agencies/persons indicated below, and I also authorize the indicated sources to release information/documentation regarding my case to PBS Psychiatry:
Person for Release of Information (e.g. parent, loved one, therapist, PCP)*

First NameLast Name
Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Fax Number
Please enter a valid phone number.
Signature

Clear
Date

MonthDayYear
Date
I understand that I may revoke this consent at any time by notifying PBS Psychiatry in writing, except to the extent that action has been taken in reliance on my consent. A photocopy of this authorization is to be considered as valid as the original document.

Any combination of the following or all of the following may be released to or obtained to PBS Psychiatry:

1. Presence in therapy/treatment/intervention/contact/visits (admit/discharge date)

2. Complete or summary Medical Record

3. Brief Description of Medication History

4. Admission Psychiatric Assessment

5. Information Necessary for the Processing and Payment of Program/Facility Billing

Possible reasons for why this information is needed:

1. Provide ongoing treatment/continuing care

2. Obtain insurance/employment/government benefits

3. Provide educational services (e.g. parent education)

4. Coordinate services with authorized officials

5. Coordinate program intervention efforts with my family/significant other/concerned person
PBS Psychiatry

100 S. Broad Street

Suite 622

Philadelphia, PA 19110

Phone 267-996-3765

Fax 855-959-1690

Email: contact@pbspsychiatry.com

Website: PBSPsychiatry.com

Philadephia Better Stories Psychiatry Consent for Release of Information

PBS Psychiatry Policy Acknowledgement and Consent for Treatment