*You may use this form to allow your mental health provider to access and use your health information. Your choice on whether to sign this form will not affect your ability to receive treatment or payment for mental health treatment.

By signing this form, I voluntarily authorize, give my permission and allow use and disclosure:

Compete Family Health, LLC dba Complete Family Psychiatry

99 6th Street SW

Suite 101

Winter Haven, FL 33880

Phone: 407-268-6668

Fax: 877-352-0071

 

PURPOSE: To provide me with medical and/or psychatric treatment and related services and products, and to evaluate and improve patient safety and the quality of medical care provided to all patients.

EFFECTIVE PERIOD: This authorization/permission form will remain in effect until my death or the day I withdraw my permission.

REVOKING MY PERMISSION: I can revoke my permission at any time by giving written notice to the person or organization.

In addition:

• I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above.
• I understand that there are some circumstances in which this information may be redisclosed to other persons (i.e., court order)
• I understand that refusing to sign this form does not stop disclosure of my health information that is otherwise permitted by law without my specific authorization or permission.
• I have read this form in it's entirety and agree to the disclosures above from the types of sources listed.