Release of Information Form

Patient Name
Patient DOB

MonthDayYear
Date
CONFIDENTIAL
CONSENT TO RELEASE MENTAL HEALTH, MEDICAL, OR SUBSTANCE ABUSE RECORDS
I authorize disclosure of records/information about me between:
Michigan Psychiatric &: Primary Care Clinic, PC and:
Name
Address
City, State, Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
The following information is being requested, please

Disclose to the above party:
Receive Froim the above party
The following information is being requested, please:

Medical HIstoryTest ResultsOther medical (M.D./Nurse evals, notes, orders, medicationsSocial and/or Chemical Use history/assessmentMental Health Assessments/consultationsProgress Reports/NotesChange in Condition/aftercare planningDischarge summaryLimited Reports (dates, discharge status, aftercare plan)Billing/PaymentsOther
I understand that my chemical dependency records are protected under the federal regulations governing confidentiality of Alcohol and I Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that my Mental Health clinic Records are afforded protection under state law. I understand that I can revoke this consent at any time. I understand this communication will reveal my presence as a patient at a treatment facility.
This consent expires one year from today's date unless otherwise specified here

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Date
Patient Signature

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CONFIDENTIAL

CONSENT TO RELEASE MENTAL HEALTH, MEDICAL, OR SUBSTANCE ABUSE RECORDS