Mobile Mental Wellness / Mobile Wellness Incorporated provides therapy and wellness services. If you request psychiatric evaluation or medication management services through our partnered provider, we must share certain protected health information (PHI) to coordinate your care.
Third-Party Provider:
Mindful Care
Information That May Be Shared:
If you elect to pursue psychiatric services, the following information may be disclosed for the purpose of coordination of care:
Demographic information
Contact information
Insurance information
Intake assessment
Diagnosis
Treatment plan
Relevant progress notes
Medication history (if applicable)
Information will be limited to what is reasonably necessary to coordinate services.
If you do not request psychiatric services through this third-party provider, your information will not be shared.
Purpose of Disclosure:
To coordinate psychiatric evaluation, medication management, and continuity of care.
Expiration of Authorization:
This authorization will remain valid for one (1) year from the date of signature unless revoked in writing earlier.
Your Rights:
You may refuse to sign this authorization.
Your refusal will not affect your ability to receive therapy services from Mobile Mental Wellness.
You may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on it.
You have the right to receive a copy of this authorization.
Authorization Consent
I understand that if I request psychiatric services through the above-named provider, my information may be shared as described above. I voluntarily authorize this disclosure for the purpose of coordinating psychiatric care.