Consent for Release of Confidential Information

Consent for Release of Confidential Information
Please complete as much information as possible.
Your Name:*

First NameLast Name
Your Date of Birth:*

MonthDayYear
Name of the organization you wish Evergreen Therapy Center to communicate with:*
The provider(s) and/or staff that treated you or the individuals that you want us to request information from:
Address of the Organization:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
The boxes below give your previous provider and/or someone else permission to send us records or speak with us.
All Treatment Information/RecordsPsychological EvaluationClosing/Discharge SummaryTreatment PlanStatement of ChargesAssessment and DiagnosisProgress NotesOther
All Treatment Information/Records (check this box by itself if you are transferring care, need an evaluation at another clinic, or want us to talk to someone in depth about your treatment)Psychological EvaluationYou are a current client (check this box by itself if you are just transferring your care to us or you had treatment somewhere else and you want us to have those records but don't need us to talk to anyone)Closing/Discharge SummaryTreatment PlanStatement of ChargesAssessment and DiagnosisProgress NotesOther
I am transferring care to Evergreen Therapy CenterI want another provider to have my records from Evergreen Therapy CenterI had care somewhere else and I want my provider at Evergreen Therapy Center to have those recordsI want a partner, parent, or other person to know about my treatment.I want my lawyer to have my treatment recordsOther
I understand that this release is voluntary. I can refuse to sign this authorization. If you are receiving medication management and have certain medical conditions, we may not be able to prescribe medication without the ability to review past medical treatment records.

I understand that recipients of the information released may possibly re-release this information without prior authorization and once re-released may not be protected by federal privacy regulations.

I understand that if the person(s) or organization authorized to receive this information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. However, there may be other federal or state laws that require the information to remain confidential.

I understand that I may revoke this release at any time, otherwise this release will automatically expire one year from the date of signature.

I also understand that I may revoke this authorization before it expires by providing a written revocation.

I further understand that I have the right to inspect disclosed information under appropriate conditions established by my provider.
All options(email, fax, phone/verbal, text)FaxEmailPhone/Verbal CommunicationText Messaging
SPECIFIC AUTHORIZATION FOR THE RELEASE OF INFORMATION PROTECTED BY STATE OR FEDERAL LAW

No information released under this authorization may be re-disclosed without the written permission of the client.

We need your permission to request information about the categories below. We can still communicate general information about mental health but will exclude any areas below that are not checked.
YesNo
YesNo
YesNo
Signature *

Patient/Authorized Representative
Date*

MonthDayYear
Date
Date*

MonthDayYear
Date
Should be Empty:

Consent for Release of Confidential Information

The boxes below give your previous provider and/or someone else permission to send us records or speak with us.