Coordination of Care

Is there a healthcare provider that you would like Silver Linings Counseling to coordinate your care with? (Medical Office, Doctor, Psychiatrist, Physician's Assistant, Nurse Practitioner, etc.)*

YesNo

Client Name*

First NameLast Name

Date of Birth*

Date

Name of Person Completing Form

First NameLast Name

Relationship to Client

Age

As noted below the following are authorized to:

Disclose InformationReceive InformationExchange Information

Doctor and/or Clinic Name*

Doctor/Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Doctor/Clinic Phone Number*

Please enter a valid phone number.

Doctor/Clinic Fax #*

Please enter a valid phone number.

Information to be Disclosed

Other specified information

Amount of Information to be Disclosed

Most recent carePrevious three monthsEntire recordOther, specify

Other specified amount of information

By filling out this form, you hereby authorize Silver Linings Counseling to exchange information regarding your mental health and/or substance use treatment and medical health care for the purpose of coordination of care as may be necessary for the administration and provision of your health care coverage.

Information exchanged may include information on mental health care of substance use treatment as protected under 42 CPR Part 2 (respecting substance abuse records) and/or state laws respecting confidentiality of records and patient communications with health care providers and in compliance with HIPAA regulations.

You understand that this authorization shall remain in effect for the duration of your treatment or until you submit written documentation to revoke it. You understand that you may revoke this authorization at any time and must do so in writing to your mental health care provider and/or Silver Linings Counseling. You also understand it is your responsibility to notify Silver Linings Counseling if you choose to change your primary care doctor.

Signature

Email*

example@example.com

Date