Medical Record Release Form
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person/Organization to Release Information
HealthCare Provider/Physician/Medicare Contractor Name
Title
First Name
Last Name
Organization Name
Phone Number
Fax Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person/Organization to Receive Information
Name
First Name
Last Name
Organization
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Fax
Release Details
I, the patient, authorize and request the disclosure of all protected information I select below full and complete.
*
Bio-Psycho Social
Treatment Plans
Medication Log
Psychiatric Evaluation
Case Management Assessment
Case Management Service Plan
Safety Plan (If Applicable)
All The Above
I, the patient, agree with the following statements:
*
I understand this authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.
I understand I have a right to revoke this authorization in writing at any time, except to the extentinformation has been released in reliance upon this authorization.
I understand the information released in response to this authorization may be re-disclosed to otherparties.
I understand any facsimile, copy or photocopy of the authorization shall authorize me to release the records requested herein.
I understand this authorization shall be in force and effect until twelve months from the date of execution, at which time this authorization expires.
Consent to Contact. By submitting this form, you are consenting Suncoast Mental Health Center to contact you via telephone (including cell phones), text messages, facsimile, email or other internet facilities, with respect to services, billing, agency updates, community resources, and other offerings. Calls may be live or pre-recorded and, calls or texts may be made via an automated dialing system. Voice and data rates may apply. Note that an individual has the right under the Privacy Rule to request and have a Suncoast Mental Health Center provider communicate with him or her by alternative means or at alternative locations, if reasonable. See 45 C.F.R. § 164.522(b).
*
Please capture a picture of your driver's license or passport
If signing on behalf of a patient, please complete the below:
Name
First Name
Last Name
Relationship to Patient:
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: