Vida Sarkodie Inc Record Release Consent

VIDA SARKODIE INC

230 US HIGHWAY 206 BUILDING 3, SUITE 3, FLANDERS, NJ 07836
Authorization to Release Information

FOR THE RELEASE OF PROTECTED MENTAL HEALTH INFORMATION
By signing this form, confidential psychological and psychiatric information can be released to and/or discussed with the people or agencies listed below unless noted by exclusions or limitations. This form is signed voluntarily and may be revoked at any time. All disclosures made pursuant to this form are valid as long as they were made before the date of revocation.
Patient Name: First Name Last Name Patient Date of Birth: Date .
1. I authorize my provider to RELEASE RECEIVE psychological/psychiatric mental health information to/from the SECOND PARTY as directed below:
2. SECOND PARTY
Name: First Name Last Name . Street Address Address Line 2 City: State Zip Fax Number: Area Code Phone Number Type here
3.TYPE OF INFORMATION TO BE DISCLOSED

I authorize disclosure of all health information, including information relating to medical, pharmcy, mental health, substance abuse, and psychotherapy. I authorze only the disclosure of the following information.tion Type here
4.PURPOSE
My health information is being disclosed at my request or at the request of my personal representative or My health information is being disclosed for the following purpose
5. Note any exclusions or limitations here
Type here
I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is not dependent on my signing this authorization. By signing below, I acknowledge that I have read and understand this document and that I have voluntarily given my provider authorization to disclose my records. I understand that I may revoke this authorization at any time by providing a written notice to my provider, however the revocation will not have an effect on any actions taken prior to the date my revocation is received. I understand that my information may be redisclosed by the authorized person/organization receiving the information, and at that point, the information may no longer be protected under the terms of this agreement. This authorization will expire one year following the date signed unless revoked in writing.
Signature

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Date

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Date
Signature Authorization is given on this patient's behalf due to being a minor or unable to sign.
Legal Guardian/Personal Representative Signature

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Date

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Date
Should be Empty:

VIDA SARKODIE INC

Authorization to Release Information