Release of Confidential Information

Release of Information (ROI) Authorization Form for Mental Health
I First Name* Last Name*, hereby authorize Atlanta Telehealth, LLC,
to:*

Release of InformationReceive Information
Information to be disclosed:*

Psychiatric AssessmentMedication Records
Purpose of disclosure:*

Continuity of CareLegal PurposesPersonal UseOther
Recipient of Information:
Name/Organization:*
Address:*
Phone Number:*
FAX Number*
Case ID (if applicable)
Expiration of Authorization:
This authorization will expire on 90 days from the date of signature
I understand that:*

I may revoke this authorization at any time by providing written notice to Atlanta Telehealth, LLC, except to the extent that information has already been disclosed based on this authorization.The information disclosed may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy regulations.This authorization is voluntary, and I may refuse to sign it without affecting my treatment, payment, or eligibility for benefits.A copy of this form is as valid as the original.
Acknowledgement
- I may revoke this authorization at any time by providing written notice to Atlanta Telehealth, LLC, except to the extent that information has already been disclosed based on this authorization.
- The information disclosed may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy regulations.
- This authorization is voluntary, and I may refuse to sign it without affecting my treatment, payment, or eligibility for benefits.
- A copy of this form is as valid as the original.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Release of Information (ROI) Authorization Form for Mental Health