Release of Information Form

Patient Name

Patient DOB

Date

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.Format: (000) 000-0000.

Fax Number

Please enter a valid phone number.Format: (000) 000-0000.

The following information is being requested, please

The following information is being requested, please:

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

Date

Patient Signature

Date

CONFIDENTIAL

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