The Center For Psychology ROI

AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Patients Name

Date of Birth

Date

Authorized Individual's Name

Name of parent or guardian or patients name if not applicable

To/ From the following individuals and entities:

My insurance and managed care companies:My health care providers

I hereby authorize The Center For Psychology, P.A., it's employees, officers and agents to disclose and obtain the individually identifiable health information regarding transmitted or maintained in any form or medium including the following information: diagnosis, treatment plan and test results if applicable.

Please Enter Doctor's Name

Doctor's Name

Doctor's Phone #

Doctor's Fax #

Additional Doctor's Name

Doctor's Phone #

Doctor's Fax #

Additional Doctor's Name

Doctor's Phone #

Doctor's Fax #

Please check if there are any additional individuals or entities and add their information below.

Please list any additional individuals or entities

I understand I have the right to revoke this authorization in writing except to the extent that The Center For Psychology PA has taken action or has relied on the authorization. This Authorization may be revoked by my requesting in writing and delivering a copy of the same to The Center For Psychology, PA. This authorization will expire 12 months from first date of service.

Once the uses and disclosures have been made, pursuant to this authorization, they may be subject to redisclosure by any recipient and no longer protected.

The Center For Psychology, P.A. will not condition treatment or payment on my providing authorization from this use or disclosure except to the extend provision of health care is solely for the purpose of creating protected health information for disclosure to a third party on provision of an authority for disclosure of the protected health information to such third party.

Patient's Signature

Date

Date & Signature of Personal Representative

Nature of Representative's Authority