AUTHORIZATION TO RELEASE INFORMATION

120 East Trinity Place  Decatur, GA 30030 Phone (404) 378-2300 Fax (404) 378-2394

CLIENT INFORMATION (Please enter the name of the person who received services from PTP and for whom you need records.)

This document authorizes Pathways Transition Programs, Inc. (PTP) to release psychological, psychiatric, and other general medical records including substance misuse or addiction information to the requester specified below following Georgia State Statues and Federal Administrative Rules and Regulations.

REQUESTER INFORMATION (Please enter your name or the name of your organization/business

MANNER OF RELEASE (of PTP Documents)

• PTP specializes in psychotherapy and does not release confidential psychotherapy notes. HIPPA defines psychotherapy notes as "notes recorded, in any medium, by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the of the individual’s medical record." PTP psychotherapy notes are only released via subpoena

or court order and will be supplied within 30 days. In place of psychotherapy notes, you may request a formal summary document, which will be provided within 30 days.

• If this release is for court ordered psychological evaluation, the evaluation will be used as evidence in court. It will be released to the referring agency or attorney; you may request information from that agency or attorney. Your consent can be withdrawn at any time, but we cannot recall information we have already shared in order to comply with your consent.
• You may request an amendment to your medical record in writing. The written amendment, or an amendment denial with an explanation, will be mailed to you within 60 days after receipt of your request.

• For documents transferred electronically (email and/or fax), the administrative retrieval fee is $25.88. There are no additional charges for records transmitted electronically. 
• For documents prepared for pick up in any PTP office (or mailed), the administrative retrieval fee is $25.88 plus: 97 cents for 1-20 pages. 83 cents for 21-100 pages. 66 cents for 100+ pages. + postage (if mailed)

(2015 Georgia Department of Community Health Medical Records Division fee schedule)

• If your services are funded by the Department of Family and Children Services (DFCS), you must request your documents directly from your county DFCS office. DFCS personnel will contact PTP for your records and retrieval fees will be waived.
• PTP also provides medical records at no charge for disability benefit or vocation rehabilitation programs.

Disclosed information is protected by Federal Rules governing confidentiality rules (42 CFR part 2 The Federal Rules prohibit recipients from making any further disclosure of this information unless the subject of the material provides additional written permission (42 CFR Part 2 This general authorization for the release of medical or other information is not sufficient for this purpose. Also, Federal Rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.

I had the opportunity to ask questions and they have been answered; I understand all information contained in this document.

I voluntarily authorize the information specified above to be obtained from or released to PTP; it will be held in strict confidence. I understand my information cannot be re-released by a recipient without my written consent. I understand this authorization will remain in effect until I specify an expiration date. If I have questions concerning any of this content in the future, I will ask my clinician.

I release PTP from any legal responsibility that may arise from the release of the above requested information.