Authorization for the Release of Information
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
I (the patient) or the guardian of the listed patient request that the following organization disclose my personal health information:
*
Serenity Bay Health
Other
The patient listed above, or their guardian authorize protected health information be disclosed to the following organization or individual:
*
Serenity Bay Health
Myself (the patient listed above)
A different individual / Company / Organization
Agency or Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Street Address
City
ZIP
State
Agency Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Agency Email
example@example.com
The following information may be shared or exchanged:
*
Assessment
Nursing or medical information
Diagnosis
Discharge information
Psychological Evaluation
Continuing care plan
Medication Review Notes
Treatment plan; progrress in treatment
Appointment Dates and Ttimes
Demographic information
Substance use and/or treatment
Other
Additional release options
I authorize the release of all information options listed above, excluding psychotherapy notes (See below option)
Psychotherapy notes - (Cannot be combined with any other disclosure, notes are sensitive in nature and it is advised to discuss with your therapist prior to signing. A signature will not guarantee release nor will records be released in certain situations unless compelled.)
Please select a reason for needing these records:
*
Coordinate Care with Another Provider
Legal Reasons (e.g., court, disability)
Personal Use/ My Records
Insurance Purposes
Other
I understand that:
I can cancel this permission at any time. I must cancel in writing and send or deliver cancellation to releasing facility or practice named above. Any cancellation will apply only to information not release by facility or practice.
This is a full release including the information detailed above
Once my health information is released, the recipient may disclose or share information with others and my information may no longer be protected by federal and state privacy protections.
Refusing to sign this form will not prevent my ability to get treatment, payment, enrollment in health plan, or eligibility for benefits.
*
I have read, understand and agree with the terms listed for the Authorization for the Release of Confidential Information. This release will expire one year from the date listed below unless otherwise specified here:
First Name
*
Last Name
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Guardian or Patient
*
I am the patient
I am the parent or guardian of this patient (Parent/Guardian, if minor or person signing on patient's behalf)
Continue
Continue
Should be Empty: