Relax Your Mind Services Standard Authorization For Disclosure Of Mental Health Treatment Information

Standard Authorization For Disclosure Of Mental Health Treatment Information

I _____________________[Insert Name of Patient/Client], whose Date of Birth is ________bauthorize RELAX YOUR MIND SERVICES, LLC to disclose to and/or obtain from:

__________________________[Insert Name of Person or Title of Person or Organization] the following information:

Patient's Name*

First NameLast Name

Patient's Date of Birth*

Date

Patients Email*

example@example.com

Insert Name of Person or Title of Person or Organization*

Phone Number*

Please enter a valid phone number.

Fax Number*

Please enter a valid phone number.

Email*

example@example.com

Please type each item to be disclosed: 1.Assessment 2.Psychosocial Evaluation 3.Psychiatric Evaluation 4.Current Treatment Update Information 5. Presence/Participation in Treatment 6.Educational Information 7. Continuing Care Plan 8.Demographic Information 9.Diagnosis 10.Psychological Evaluation 11.Treatment Plan or Summary 12.Medication Management 13.Nursing/Medical Information 14.Discharge/Transfer Summary 15.Progress in Treatment 16. Psychotherapy Notes* (*cannot be combined with any other*

Purpose: This information may be used or disclosed in connection with mental health treatment, payment, or healthcare operations. If the purpose is other than as specified above, please specify:*

Revocation I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to and date :*

Form of Disclosure Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically. Redisclosure I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protections.

Signature of PatientClient*

Date*

Date

Signature of Parent Guardian or Personal Representative Date