Disclosure and Consent

Patient Name

First NameLast Name

Patient Date of Birth

MonthDayYear

I direct Raleigh Wellness Behavioral Health Staff to disclose and release my protected health information to the named individual below:

Name of Authorized Person

First NameLast Name

Relationship to Patient:

What type of doctor?

Phone of Authorized Person

Area CodePhone Number

Health Information to be disclosed upon the request of the person named above: (check only 1 option)

Coordination of Care / Collateral Communication Policy

If this Disclosure and Consent Form is completed authorizing your medication management provider at Raleigh Wellness Behavioral Health to communicate directly with outside providers or individuals involved in your treatment or care, a fee of $75 will be charged to the patient for professional consultation calls up to 20 minutes in length.

These communications require dedicated professional time outside of a scheduled appointment and are not reimbursed by insurance companies. Therefore, this service is considered an out-of-pocket expense and is the responsibility of the patient.

Patient Signature

Date

This disclosure and consent does not have an expiration date to facilitate coordination of care. This form is valid until the patient revokes in writing.

if "other" please tell us who or what company/entity