Referral Form | Chosen Care, Inc.

Release of Information

This form will take approximately 10 minutes to complete..
Name of Chosen Care Manager assigned to your family:*
Please enter the name of your Chosen Care Manager.
Name of individual completing form:*

Your First NameYour Last Name
Email:*
Phone Number:
Please enter a valid phone number.
Information Release

Please fill in the appropriate information for the person/organization you are allowing us to speak with. Please be as detailed and specific as possible.
I authorize Chosen to disclose the following Protected Health information to:*

YesNo
Organization / Individuals Name:*
Please name the organization we are allowed to speak with. This would be the name of your foster care organization, church, counselor, CPS, etc..
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
This release cannot exceed one year from when the release comes into effect.
This release is effective from:

MonthDayYear
Date
This release is effective to:

MonthDayYear
Date
Organization / Individuals Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Information to include the following:
Please specify what we are allowed to talk to this person or agency about. A sample answer is: “Details related to the services I am receiving and parent coaching progress notes.” You can also be very general, for example: “Anything I have shared with my Care Manager.” You can be very specific as well, for example: “You may confirm that I am engaged in services with Chosen.”
This protected health information is being used for the following purposes:*
Please explain why we are communicating with this person or organization. This can be very brief, such as “The information is being used to keep my case worker informed about my parent coaching sessions with Chosen.”
The individual completing the form may withdraw their authorization at any time, except to the extent that the action has already been taken.
By checking the box "Yes" you are authorizing Chosen to disclose the following Protected Health Information:*

YesNo
Referrals Signature:*
Date

MonthDayYear
Date
Witness to Signature:
Should be Empty:

Release of Information

Information Release