RELEASE AND REQUEST OF HEALTH / CONFIDENTIAL RECORDS

RELEASE AND REQUEST OF HEALTH / CONFIDENTIAL RECORDS

Alis Family Psychiatry - Tina Matthews-Hayes, DNP, APRN, FNP-BC, PMHNP-BC
For any inquiries, kindly email alisfamilypsychteam@hushmail.com or contact us at (757) 239-2293 or (503) 922-1999

Please read each section carefully and provide complete and accurate information. Incomplete forms may result in delays or denial of the request.
Which clinic is this for?*

OregonVirginia
Request Date *

MonthDayYear
Date
Patient's Full Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient’s Social Security Number*
Insurance Guarantor’s Social Security Number*
If same as patient, please re-enter
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Phone Number*
Please enter a valid phone number.
Patient's Email Address*
example@example.com
Insurance carrier:
Patient gives permission to (please select one below)*

Disclose to(outbound request)Obtain from (inbound request)Exchange information with
Name of Requested Individual/Facility/Clinic/Agency/Organization Name/Other
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Requested Facility's Phone Number
Please enter a valid phone number.
Requested Facility's Fax Number
Please enter a valid phone number.
Requested Facility's Email Address
example@example.com
Information to be released/ disclosed:

All RecordsIntake/Initial assessmentMedication listProgress notesTreatment plansScheduling & appointment detailsDiagnosis codesLaboratory reportsNeurocognitive test resultsOther
For others, please elaborate your request further.
This authorization will last for one year after the date you sign unless you enter a different date or expiration date here:*

MonthDayYear
Date
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Patient's Signature or Authorized representative*

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Confidentiality & HIPAA Notice
This e-mail message and any documents attached to it are confidential and may contain information that is protected from disclosure by various federal and state laws, including the HIPAA privacy rule (45 C.F.R, Part 164) This information is intended to be used solely by the entity or individual to whom this message is addressed. If you are not the intended recipient, be advised that any use, dissemination, forwarding, printing, or copying of this message without the sender's written permission is strictly prohibited and may be unlawful. Accordingly, if you have received this message in error, please notify the sender immediately by return e-mail or call (503 922-1999), and then delete this message.

Office address: 6350 Center Dr Ste 102 Norfolk, VA 23502-4107
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RELEASE AND REQUEST OF HEALTH / CONFIDENTIAL RECORDS

Confidentiality & HIPAA Notice