Release of Information

Release of Information
This form when completed and signed by you, authorizes the release of protected health information from your clinical record to the doctor/facility/therapist you designate
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
I authorize Raleigh Wellness &Behavioral Health to Obtain OR release records to the entities (clinic, hospital provider/s listed below)*

Obtain fromRelease to
Entity Name (Clinic/hospital/provider)*
Entity Fax (FAX NUMBER IS REQUIRED, should we receive a form with no fax, we will ask you to kindly fill this form again)*
Information allowed to be released:*

Progress notesEvaluations/AssessmentsLabs/ImagingHospitalization/Discharge SummaryMedical HistoryMedication Report/ListCommunicationOther
Purpose of Release*
I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by a recipient of such information and it is possible that once disclosed, the privacy of the information may no longer be protected under federal medical privacy law. I understand that this authorization gives permission to release the information above which may include drug/alcohol abuse, treatment, and psychological or psychiatric impairments, HIV/AIDS or physical conditions. A fee may be charged for copying the protected health information
Patient / Guardian Signature*

Clear
Date

MonthDayYear
Date
Should be Empty: