Release of Information / Receiving Medical Records

Release of Information / Receiving Medical Records
By signing this form, I authorize Premier Mental and Behavioral Services to receive confidential medical information about me, by receiving a copy of my medical records, or a summary or narrative of my protected health information or a discussion of my treatment with the parties listed below:
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Last 4 digits of SSN*
Patient Phone Number*
Please enter a valid phone number.
I Authorize Premier Mental and Behavioral Services to receive my private health information from the following recipient:*

I Authorize Premier Mental and Behavioral Services to receive my private health information from the following recipient:
Name*
Address*
Phone Number*
Fax
This release is valid for one year unless otherwise specified below. All records may be included with the exception of therapy progress notes as they are protected information and cannot be released. Please be advised that any records requested from our office may take up to 14 calendar days to be completed. Any requests being forwarded to another healthcare provider will be free of cost. However, records being released to any other entity including self will have a cost associated with it.
Name of Guardian / Relationship to Patient:
Date:*

MonthDayYear
Signature*

Clear
Should be Empty: