Thomas Park MD & Associates- RELEASE OF RECORDS

Thomas Park, M.D. & Associates
23077 Greenfield Rd. Suite 430
Southfield, MI 48075
Phone: (248) 552-0044
Fax: (248) 423-7777

Prescribers	Providers
Thomas Park, MD Oksana Lidke, DNP, PMHNP Dr. Yan Yan Wang, DNP, PMHNP	Robyn Glickman, PhD, LLP, CAADC Raymond Small, PhD Gasper Novara, LMSW Janice Wright, LMSW Patricia Willis, LLP	Carolin Mann-Bomar, M.S., LLP Hilary Sircus, M.S., DLLP Rula Mohammad, LLP Ania Austin, LLP Angela Bologna, TLLP

HIPPA Privacy Authorization Form

***Authorization for use or disclosure of protected health information PHI This is required by the HIPPA, 45 C.F.R. Party 160 and 164.***
Release of RecordsRequest for Records
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
I, (Name)______ authorize Thomas Park MD & Associates to use/request and disclose/receive the PHI to/from: the following:
Office/Facility or Individual Requesting
Office/Facility or Individual Phone #
Office/Facility or Individual Fax #
This Authorization is valid from today's date through (Date). *If no date is selected, authorization will not expire until notice is received in writing

MonthDayYear
Date
All RecordsLab/Test ResultsAttendanceMedication ListProgress NotesFinancial Information/BillingDiagnosesPsychotherapy NotesEvaluationsPsych Testing ResultsOther
Parent/Guardian Signature

Powered by Jotform SignClear
Parent/Guardian Printed Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

HIPPA Privacy Authorization Form