CONSENT FORM FOR RELEASE OF MEDICAL RECORDS

CONSENT FOR RELEASE OF MEDICAL RECORDS - Dan Short, Ph.D.

9855 E Larkspur Dr., Scottsdale, Arizona 85260, Email: dan@iamdrshort.com, Phone: (480) 329-5359
Patient's Full Name
First, Last
I hereby authorize the release of my medical records, created by Dan Short,

Ph.D., to the individuals listed below for the purpose of:
Specify the purpose of the release
Release to

First NameLast Name
Recipient's Phone Number
Please enter a valid phone number.
Recipient's Email
example@example.com
Recipient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I acknowledge that this consent form allows Dan Short, Ph.D., to access, review, and disclose my medical records as required for the stated purpose.

I am aware that this release will remain valid and in effect until I formally revoke this permission in writing.

I understand that the information disclosed may include, but is not limited to, medical and psychological evaluations, treatment plans, progress notes, test results, and any other relevant medical or mental health

I acknowledge that my privacy rights will be respected and that the disclosed information will be handled in accordance with applicable laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA) and other relevant state and federal laws.

I hereby release Dan Short, Ph.D., and any individuals or entities involved in the release, transfer, or disclosure of my medical records from any liability that may arise from the release of said records for the specified purpose. I understand that I have the right to request a copy of this signed consent form for my records.
Patient's Full Name
Signature

Clear
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Should be Empty:

CONSENT FOR RELEASE OF MEDICAL RECORDS - Dan Short, Ph.D.