Release of Information

Federal law requires your specific authorization for release to appropriate parties any information about your treatment for certain conditions. Please check and sign all pertinent statements below giving your permission to communicate with the following individual, agency, or organization on your behalf:

Patient Name*

First NameLast Name

Date of Birth*

Date

I hereby authorize:

Nicodemus M. Watts, MD, DFAACAP
3760 Convoy Street, Suite 113
San Diego, CA 92111-3743
Phone: (858) 598-5207

To (check all that apply):

DiscloseObtainFaxE-mail

From the following individual, agency, school or organization:*

Individual, Agency, or Organization to be contacted:

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Please enter a valid phone number.

Fax

Please enter a valid phone number.

Email

example@example.com

The following information:

Other

Please specify

The information is required for:

Diagnostic assessmentPlanning ServicesCoordination/collaboration of client's carePlanning treatment

Other

Please specify

_____________________________________________________________

I understand that I may revoke this consent at any time by providing written notice. After one year this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information.

Authorization to Release Information