Authorization for Release of Information
Bio Psychiatry Therapeutic Services, LLC

I understand that Maryland law requires each client's consent for the release of confidential information related to mental health or developmental disability. With this understanding, I hereby waive any right to confidentiality arising under Maryland law and authorize the release of records of information, but only the extent specified below.

I authorize Bio Psychiatry Therapeutic Services, LLC to release and/or receive the following information concerning myself or my child:

The above information is only to be released to, and/or from, the patients Primary Care Provider (PCP), Inpatient Mental Health Hospitalization Reports and Outpatient Reports from Previous Providers:

I understand that I can revoke this authorization at any time by giving written notice to the parties named above. I also understand that I have the right to examine and copy the information disclosed.

I hereby release the parties named above from any liabilities for release of this information.

Note: This document is a template only. It does not reflect the requirements of your state’s laws. You should consultwith advisors (your state or local medical or specialty society, or legal or other counsel) familiar with your state’sprivacy laws prior to using this document.