Synaptic Psych - Authorization for Disclosure and Use of Psychotherapy Notes

Authorization for Disclosure and Use of PSYCHOTHERAPY Notes
Patient's Full Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Email of patient or parent/guardian*
example@example.com
Please select which option you are requesting from us. You may pick only one option for this release. At the end of this form, you can select to complete an additional form
I hereby give permission to the clinicians and staff at Synaptic Psych, formerly NeuroScience & TMS Treatment Center:*

To Release (Send or Disclose) the following psychotherapy notesTo Request (Obtain or Collect) the following psychotherapy notesTo both Release (Send or Disclose) and Request (Obtain or Collect) the following psychotherapy notes
Select which type of medical or psychiatric information:*

All psychotherapy notes pertaining to the patient listed aboveOnly a Summary of Care written by the primary physician, clinician, or therapist pertaining to the patient listed aboveOther specific information pertaining to the patient listed aboveOther
This authorization, or a photocopy thereof, authorizes, directs, and specifically requests that Synaptic Psych formerly NeuroScience & TMS Treatment Center acting on behalf of the physicians, clinicians, and therapists, Release (Send or Disclose) and/or Request (Obtain or Collect) patient records pertaining to the patient listed above to/from the physician, clinician, therapist, hospital, or agency listed below:
Name:*
Address:
City/State/Zip:
Phone:*
Fax:
If you are requesting records to be Released, how would you like those records Released? (Select all that apply)*

FaxSecure Email, if possibleMail, Paper CopiesMail, via USB drive
By signing below, I am representing that: I am at least eighteen (18) years old, and I am fully competent to give my consent; I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation. I understand that this release shall expire one year from the date of the signature below. I may revoke this consent at any time by providing written notice of the revocation to the Custodian of Records for the healthcare physician, clinician, or therapist identified above, except to the extent that the action has been taken already in reliance upon this authorization. I understand that I may refuse to sign this authorization and that it is strictly voluntary. My treatment, payment, or enrollment or eligibility for benefits may not be conditioned on signing this authorization. I understand that there exists the potential for my protected health information to be re-disclosed by the recipient identified above and no longer protected by the Privacy Rule set out in the Health Insurance Portability and Accountability Act and federal privacy rules and regulations. Any health care physician, clinician, therapist and his/her/their employees, officer, agents, and associated physicians who provide information pursuant to this Authorization are hereby released from any legal responsibility or liability for the release of the above information to the extent indicated and authorized herein. I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed. I understand that there is a statutory privilege that prohibits disclosure of communications between a patient and psychiatrist, psychiatric clinician, and therapist in Tennessee, and I hereby waive this privilege with regard to this release.

I acknowledge records sent to other healthcare clinicians (physician, clinicians, and therapists) for continuity of care will not incur charges, however, personal copies, insurance copies (life, disability, and workers compensation) and attorney copies will incur charges per office policies.

This information has been disclosed to you from records protected by the Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol / drug abuse patient. (52 FR 21809, June 9, 1987; 52 FR 41997, Nov. 2, 1987)

This consent shall be effective from the date of signature and shall expire in 1 (one) year. I also understand that I may revoke this consent or authorization at any time providing I notify the Clinic, in writing to this effect. Revocation has no effect on actions previously taken.
1a. Are you completing this release to request that we SEND psychotherapy notes somewhere?

YESNO
1b. This authorization, or a photocopy thereof, authorizes, directs, and specifically requests that the NeuroScience & TMS Treatment Center acting on behalf of the physicians, clinicians, and therapists, SEND patient psychotherapy notes to:*
Name | Address | Phone number
2a. Are you completing this release to request that we COLLECT/REQUEST psychotherapy notes from somewhere?

YESNO
2b. This authorization, or a photocopy thereof, authorizes, directs, and specifically requests that the NeuroScience & TMS Treatment Center acting on behalf of the physicians, clinicians, and therapists, COLLECT/REQUEST psychotherapy notes from:
Name | Address | Phone number
I hereby give permission to physicians, clinicians, therapists and staff at NeuroScience & TMS Treatment Center to share All psychotherapy notes pertaining to the above-referenced patient.
In what way would you like us to Send the information?*

Fax records, or securely email the informationMail recordsOTHER
In what way would you like us to Collect the information?*

Fax records, or securely email the informationMail recordsOTHER
OTHER:
If you selected other, list here what OTHER is defined as
By signing below, I am representing that:

I am at least eighteen (18) years old, and I am fully competent to give my consent;

I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.

I understand that this release shall expire one year from the date of the signature below.

I may revoke this consent at any time by providing written notice of the revocation to the Custodian of Records for the healthcare physician, clinician, or therapist identified above, except to the extent that the action has been taken already in reliance upon this authorization.

I understand that I may refuse to sign this authorization and that it is strictly voluntary. My treatment, payment, or enrollment or eligibility for benefits may not be conditioned on signing this authorization.

I understand that there exists the potential for my protected health information to be re-disclosed by the recipient identified above and no longer protected by the Privacy Rule set out in the Health Insurance Portability and Accountability Act and federal privacy rules and regulations.

Any health care physician, clinician, therapist and his/her/their employees, officer, agents, and associated physicians who provide information pursuant to this Authorization are hereby released from any legal responsibility or liability for the
release of the above information to the extent indicated and authorized herein.

I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed.

I understand that there is a statutory privilege that prohibits disclosure of communications between a patient and psychiatrist, psychiatric clinician, and therapist in Tennessee, and I hereby waive this privilege with regard to this release.
Signature of Patient /Parent or Guardian - Signature must be legible*

Clear
Full Name of adult signing this form*

First NameLast Name
This information has been disclosed to you from confidential records of which may be protected by federal and/or state law. Federal Regulation prohibits you from any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or otherwise permitted. A general authorization for the release of medical or other information is not sufficient for this purpose.
DateTime
4. Do you want to complete another Authorization to Release information?

YESNO
5. Is the other release for the release of psychotherapy notes?

YESNO
If you are having difficulties, please call or email our office.
NeuroScience & TMS Treatment Center, dba Synaptic Psych

PHONE 615-224-9800 | FAX 615-224-9840 | EMAIL medicalrecords@hopeforyourbrain.com
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Authorization for Disclosure and Use of PSYCHOTHERAPY Notes

Please select which option you are requesting from us. You may pick only one option for this release. At the end of this form, you can select to complete an additional form