Authorization to Release Protected Information

Authorization to Request Protected Information

This form gives Meadowlark Psychiatric Services permission to request your protected information be sent to Meadowlark Psychiatric Services, from designated individual(s) or agency(ies). Form must be completed in its entirety. This request is invalid if it does not contain the client’s electronic signature and date signed, or if it has expired. Client may be asked to provide original signature at the first visit to the Meadowlark offices. A copy of this form will be provided to the client.
I, as the patient or patient’s legal representative, give Meadowlark Psychiatric Services my authorization to request the information I have selected from the individual(s) or agency(ies) I have named and only for the purpose I have checked.

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 the noted releasee, 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 to:
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
Name of Individual(s) or Agency(ies) releasing information to Meadowlark.
Address of Individual(s) or Agencie(ies) releasing information to Meadowlark.*

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
I understand that this will include information relating to:

All 3 boxes must be checked
Substance Abuse (Alcohol/Drug)*
Mental Health (Includes Psychological Testing)*
HIV-Related Information (AIDS-Related Testing)*
Check the following to note consent and understanding.
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.*
Electronic Signature Disclosure
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*

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

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Should be Empty:

Authorization to Request Protected Information

I understand that this will include information relating to:

Check the following to note consent and understanding.

Electronic Signature Disclosure