PHP Referral Consent Form

PHP Referral Consent
Ifull name*authorize provider* to make a referral on my behalf to Serenity Bay Health for evaluation and potential admission to the Adolescent Partial Hospitalization Program. I consent to release of the following records to Serenity Bay Health as part of the intake process:
- Demographics including contact person and insurance
- Provider / Clinician notes last three visits / encounter
- History and Physical and or last physical
- Discharge Summary if applicable
- Medication List
I understand it may take 24-48 hours for a Serenity Bay Health intake team member to contact me.
Name*

First NameLast Name
Signature*

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Date*

MonthDayYear
Date
Referring Facility*
Contact Person*
Phone Number*
Should be Empty: