HPPGA - Records Request Form

HPPGA - Records Request Form
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
RELEASE FROM: Healing Psychotherapy Practices of Georgia, LLC | 3750 Palladian Village Drive, suite 320 Marietta, GA 30066 | tel: 770-792-0079 | fax: 1-888-394-1986 | tel: info@healingpsychotherapyga.com
Name*

Previous Names if ApplicablePrint Client First and Last Name
Client Date of Birth*

MonthDayYear
Date
TO:

Tell us who you want us to release the records to
Name*
Address*
City State Zip*
Phone*
Fax
INFORMATION TO BE RELEASED:
Psychological / Psychiatric Evaluations / Neurological Workup*

YesNo
Treatment Plans and Progress Notes including current medications*

YesNo
School Records*

YesNo
Vebal Communication*

YesNo
Other (specify):
Discharge Summary*

YesNo
PURPOSE OF DISCLOSURE:*

Continued CareSelfSpecialistPCP Communication and Care CoordinationPermission to Provide Services at SchoolDisability ClaimOther
TREATMENT DATES REQUESTED:
From: MMDDYY*
To: MMDDYY*
I understand that this information will not be disclosed to any other agency or individual without my written authorization, except as allowed by law. I also understand that my protected health information, which is disclosed with this release, may be subject to redisclosure by the recipient and no longer protected by law. HPPGA is not responsible for any alterations made on its medical record copies, which have been released to any party. I understand that I have a right to a copy of this authorization after I sign it. I understand that HPPGA will not condition treatment on the completion of the authorization.
HEALING PSYCHOTHERAPY PRACTICES OF GEORGIA
A faxed authorization is as valid as the original. The authorization automatically expires 12 months from the date it was signed or when services are terminated. I understand I can revoke this authorization at any time by sending written notice to HPPGA Privacy Official at 3750 Palladian Village Drive, suite 320, Marietta, GA 30066 except for disclosures already made based upon my original permission.

This authorization is given freely, voluntarily and without coercion.

Parental Signature Required for Clients 17 Years and Younger.

Requests are processed in the order received and within 7-10 business days.
Signature of Client or Client Guardian*

Clear
Date*

MonthDayYear
Date
Proprietary: For HPPGA Use Only---Cannot be duplicated without prior written consent from HPPGA authorities.
Should be Empty:

HPPGA - Records Request Form

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

TO:

HEALING PSYCHOTHERAPY PRACTICES OF GEORGIA