Coordination of Care with Other Medical Providers
Communication with other medical providers is important to ensure that you receive comprehensive and quality health care. This form will allow your behavioral health provider to communicate with your other medical providers. This information will not be released without your signed permission.
Patient Name
*
Date of Birth
*
A. Treating Behavioral Health Clinician/Facility Information
Name
Address
B.
PCP/Medical Clinician or Other Behavioral Health Clinician
Name
Address
Patient Clinical Information to be filled out by Doctor:
1. The patient is being treated for the following behavioral health issues
ADHD/Behavior
Anxiety
Bipolar D/O
Adjustment D/O
Depression
Other
2. The patient is taking the following prescribed medications:
Antidepressant
Antipsychotic
Anti-anxiety
ADHD
3. Expected length of treatment:
Less than 3 months
3-6 months
6-12 months
12+ months
4. Coordination of care issues/other significant information impacting medical or behavioral health:
I authorize the behavioral health practitioner listed above in Section A to release the information contained in this form to the provider listed In Section B above. The reason for disclosure is to facilitate continuity and coordination of treatment. I understand that I may revoke my consent at any time. Please check one of the boxes below:
*
I give my authorization to release any applicable mental health PHI to the physician listed above.
I DO NOT give my authorization to release any information to any other physician.
Client or Guardian Signature
*
Date
*
/
Month
/
Day
Year
Date
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