ESE Mental Health For Records Request 2023

1539 Old Valdosta Rd.
Ray City, GA 31645
Office No: 229-422-3661
Fax No: (855) 290-7561
www.esementalhealth.com
AUTHORIZATION FOR RELEASE/DISCLOSURE OF HEALTH CARE INFORMATION
Patient Name
DOB
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian or Authorized Party (if applicable)
Guardian DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I authorize the release and disclosure of my health information as described below and ESE Mental Health is authorized to obtain and discuss the following information:
Teacher Email for Vanderbilt Assessment
example@example.com
Please initial each of the following as acknowledgements to indicate understanding and consent
Information to be Released From
Phone
Format: (000) 000-0000.
Medical Records from the facility listed above will be sent to:

ESE Mental Health
1539 Old Valdosta Rd.
Ray City, GA 31645

Fax # (855) 290-7561
I understand that the provider above may not condition treatment on my signing this authorization and that I have a right to refuse to sign.
Signature of Patient or Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
** If authorization is signed by a personal representative, the representative's authority is based on
(e.g., state law, court order, POA, etc.)
FEE SCHEDULE: State and Federal laws specify a reasonable fee may be charged to offset the cost associated with the reproduction of records. No fee shall be charged for reproducing and forwarding records directly to other physicians. NoticetoBy choosing to utilize Email communication, you are acknowledging that email may not be completely secure. Selection of Email Patients: option and signature are documentation of patient and/or guardian acknowledgment of these risk and hereby grant permission to utilize email.

A fax copy, or photocopy of this consent shall be as valid as the original.
Should be Empty:

AUTHORIZATION FOR RELEASE/DISCLOSURE OF HEALTH CARE INFORMATION