Release of Information Consent Form Craig Clark, M.D., Amy Powell, MA LPE, Justin Malais PMHNP Alyssa Mielock PhD(post-doc) Tim Caldwell LPC/MHSP(temp)

2. I AUTHORIZE Nashville Neuro Psychiatric Associates; Phone: 629-203-6779 Fax: 615-678-1916

To: release information to obtain information from exchange information with the person/organization in section 3.

3. ORGANIZATION / INDIVIDUAL INFORMATION / Organization Name:

4. INFORMATION TO BE RELEASED Specific dates/years of treatment:

All health information (excludes information from a chemical dependency program & psychotherapy notes) OR indicate the specific categories to be released: Diagnosis Psychological Evaluations Discharge Summary Treatment Plans Social History Provider/Hospital Records School/Criminal

5. PURPOSE FOR DISCLOSURE: Coordination of Care Legal/Court Order Personal Request

6. I UNDERSTAND THAT: My health information is protected by federal regulation (Alcohol & Drug Abuse Patient Records, 42 CFR Part 2; and/or HIPAA 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances described in Privacy Notice. I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. Nashville Neuro Psychiatric Associates outlines the procedure for revocation. This authorization will expire in one year from the date I sign or unless I request an earlier expiration in writing. For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be conditioned on my agreement to sign and authorization (unless I am receiving care solely to create protected health information for disclosure to a third party) Communications resulting from this authorization will reveal that I receive services at NNPA. Federal confidentiality regulations (42 CFR Part 2) prohibit re-disclosure of information from alcohol & drug abuse patient records. However, HIPAA requires NNPA to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA.

7. SIGNATURE Patient's Signature:

OR Authorized Representative's Signature: Representative's Name (printed):