Authorization to Release Protected Information

I, as the patient or patient’s legal representative, give Meadowlark Psychiatric Services my authorization to release the information I have selected from the individual(s) or agency(ies) I have named and only for the purpose I have checked.

Multiple Receiving Individuals or Agencies - I understand that this form must be completed for each individual and/or agency receiving my information.

Expiration Date - I understand that this request is valid up to the expiration date stated below, and I may refuse to sign this authorization at any time. Any revocation or refusal to sign this authorization will not affect my ability to obtain treatment, payment, or my eligibility for benefits. The revocation will take effect on the day it is received in writing.

Access to Records - As a patient, I have the right to access my treatment records. Copies of the records may be obtained with reasonable notice and payment for copying cost.

Electronic Transmission of Records (Faxing/Email) - I authorize electronic transmission (fax/secure e-mail) of my medical records. If any portion of the fax/email is received by an inappropriate third party in error, I release Meadowlark Psychiatric Services, its physicians and staff, of any and all liability relating to the disclosure of said records.

Electronic Signature Acknowledgement and Consent - I accept, agree and understand that by signing the Electronic Signature Acknowledgement below, this signature is the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. If further agree my signature on this form is as valid as if I signed the document in writing.

I am requesting that my personal information, as noted below, be sent from:
Meadowlark Psychiatric Services
320 West Cherry Street
North Liberty, IA. 52317
Phone: 319-626-3084
Fax: 319-626-3084

Use the form below to complete your request OR you may also download a copy of the PDF version of this form here: Download PDF Form

Name of Client: (Individual whose information will be released.)*

First NameLast Name

Date of Birth*

MonthDayYear

Social Security Number

Email*

example@example.com

Where the information is to be sent.*

Street Address

Street Address Line 2

CityState

Zip Code

Fax*

Please enter a valid fax number.

Phone Number*

Please enter a valid phone number.

Check here if both parties will be receiving and releasing information:

Information Requested: (Select all that apply)*

Complete Records/DemographicsNotesOther

Other: Please clarify in the field provided below.

Purpose of Release*

Continuity of CareTransfer of CareOther: Please clarify in the field provided below.

Other: Please clarify in the field provided below the other purpose of release.*

Desired Release Expiration Date*

MonthDayYear

Substance Abuse*

I agreeNo AnswerNot Applicable

Mental Health (Including Psychological Testing)*

I agree

HIV-Related Information (Aids-Related Testing)*

I agreeNo AnswerNot Applicable

Substance Abuse (Alcohol/Drug)*

Mental Health (Includes Psychological Testing)*

HIV-Related Information (AIDS-Related Testing)*

I give my consent to fax and/or mail my records*

I understand that Meadowlark Psychiatric Services may receive compensation for disclosure of information released pursuant to this authorization.*

I accept, agree and understand that by signing the Electronic Signature Acknowledgement below, this signature is the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. If further agree my signature on this form is as valid as if I signed the document in writing.*

Electronic Signature of Client*

Electronic Signature of Legal Guardian (Required if client is under the age of 18.)

Authorization to Release Protected Information

I understand that this will include information relating to:

Check the following to note consent and understanding.

Electronic Signature Disclosure