GPS - Release of Medical Information

Release of Medical Information

This form serves as authorization for use or disclosure of your protected health information. Please complete all sections.
I. IDENTIFICATION
I, First Name* Last Name* DOB Date* hereby voluntarily authorize the disclosure of my mental health record.
Please complete the below fields with the PROVIDER / FACILITY'S information.
Name of the Provider/Facility the information is being disclosed by (SENDER)*
Provider/Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider / Facility Phone Number
Please enter a valid phone number.
Provider / Facility Fax Number*
Provider / Facility Email Address
Name of the Provider/Facility the information is to be provided to (RECEIVER)*
Provider / Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider / Facility Phone Number
Please enter a valid phone number.
Provider / Facility Fax Number *
Provider / Facility Email Address
II. PURPOSE
The purpose of the disclosure is*

Further Medical/Mental Health CarePersonal UseInsuranceAttorneyDisabilitySchoolResearchOther
Other:
III. THE INFORMATION TO BE DISCLOSED FROM MY MENTAL HEALTH RECORD
Disclosed information will occur in a two-way capacity, Allowing for verbal, electronic, or written communication between the above name people/organizations/agencies/facilities*
Only information related to:
Only the period of events from Date to Date
Other: (Please specify)
IV. SIGNATURE AND UNDERSTANDING
I understand that I may revoke this authorization in writing submitted at any time to Georgia Psychatry & Sleep, except to the extent that action has been taken in reliance on this authorization. If authorization has not been revoked, it will continue unless an updated release is provided. Medical records frequently contain information which may be privileged and/or confidential remarks furnished by the patient, patients family and staff. If, in the judgement of the medical staff, disclosure of the privileged/confidential information will be harmful to the patient, release of such imformation may be withheld in accordance with specific state and federal regulations. Records released may contain alcohol and drug treatment information, AIDS/HIV, psychiatrics/psychological/other mental health privileged or confidential information. Certain communications are privileged and not subject to release without your consent under state and/or federal law.

After giving due consideration to the above statement, I authorize Georgia Psychiatry & Sleep and/or members of its staff to furnish information, including verbal and/or written communication, photocopy or faxed copies of my medical records, including matters privileged under laws of the state of Georgia, and applicable federal law and regulations, to the above organization or to its agent. I further agree to indemnify and hold harmless Georgia Psychiatry & Sleep and staff from libiility that may arise from the release of the information herein requested.
Patient Name *

First NameLast Name
Guardian Name (if applicable)

First NameLast Name
Patient / Guardian Signature *

Clear
Date*

MonthDayYear
Date
If faxing records to Georgia Psychiatry and Sleep, please fax them to

770-825-9046
Should be Empty:

Release of Medical Information

I. IDENTIFICATION

II. PURPOSE

III. THE INFORMATION TO BE DISCLOSED FROM MY MENTAL HEALTH RECORD

IV. SIGNATURE AND UNDERSTANDING