AUTHORIZATION TO RELEASE INFORMATION MEDICAL RECORD REQUEST

AUTHORIZATION TO RELEASE INFORMATION MEDICAL RECORD REQUEST
120 East Trinity Place Decatur, GA 30030

Phone (404) 378-2300 Fax (404) 378-2394
CLIENT INFORMATION (Please enter the name of the person who received services from PTP and for whom you need records.)
Name

First NameMiddle InitialLast Name
DOB
This document authorizes Pathways Transition Programs, Inc. (PTP) to release psychological, psychiatric, and other general medical records including substance misuse or addiction information to the requester specified below following Georgia State Statues and Federal Administrative Rules and Regulations.

REQUESTER INFORMATION (Please enter your name or the name of your organization/business
Name
Address
Phone
Email Address
example@example.com
Email Address

The client is a minor; I am the client’s legal guardianOther Please explain
Fax
The client is a minor; I am the client’s legal guardian

I am an adult, over 18 years of age; I am the clientThe client is a minor; I am the client’s parent
IDENTIFICATION
Type
ID #
Exp Date

MonthDayYear
Date
Exp Date

Date N/A
If ID is not attached, please explain
DOCUMENTS TO BE RELEASED

Psychiatric Testing & AssessmentsOther
Drug Screen Results

AllMedical Histories & PhysicalsDischarge SummaryProgress Notes
Psychiatric Testing & Assessments

Drug Screen ResultsPsychological Testing & AssessmentsTreatment PlanCase Summary
MANNER OF RELEASE (of PTP Documents)
PURPOSE OF RELEASE?
RELEASE DURATION
Records released for how long?

FaxEmailPick up (PTP Decatur office)Continued TreatmentCase PlanningOne TimeOne YearContinuous until:Other
Continuous until
Important
PTP specializes in psychotherapy and does not release confidential psychotherapy notes. HIPPA defines psychotherapy notes as "notes recorded, in any medium, by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the of the individual’s medical record." PTP psychotherapy notes are only released via subpoena

ADMIN8-ENG–AUTHORIZATION RELEASE INFORMATION MEDICAL RECORDS REQUEST Revised 2/3/2022 PAGE 1 OF 2
Name

First NameMiddle InitialLast Name
DOB
or court order and will be supplied within 30 days. In place of psychotherapy notes, you may request a formal summary document, which will be provided within 30 days. v If this release is for court ordered psychological evaluation, the evaluation will be used as evidence in court. It will be released to the referring agency or attorney; you may request information from that agency or attorney. Your consent can be withdrawn at any time, but we cannot recall information we have already shared in order to comply with your consent. v You may request an amendment to your medical record in writing. The written amendment, or an amendment denial with an explanation, will be mailed to you within 60 days after receipt of your request.
Fees
For documents transferred electronically (email and/or fax), the administrative retrieval fee is $25.88. There are no additional charges for records transmitted electronically. v For documents prepared for pick up in any PTP office (or mailed), the administrative retrieval fee is $25.88 plus: 97 cents for 1-20 pages. 83 cents for 21-100 pages. 66 cents for 100+ pages. + postage (if mailed)

(2015 Georgia Department of Community Health Medical Records Division fee schedule)
Fee Exceptions
v If your services are funded by the Department of Family and Children Services (DFCS), you must request your documents directly from your county DFCS office. DFCS personnel will contact PTP for your records and retrieval fees will be waived. v PTP also provides medical records at no charge for disability benefit or vocation rehabilitation programs.
Redistribution of Confidential Information is Prohibited
Disclosed information is protected by Federal Rules governing confidentiality rules (42 CFR part 2 The Federal Rules prohibit recipients from making any further disclosure of this information unless the subject of the material provides additional written permission (42 CFR Part 2 This general authorization for the release of medical or other information is not sufficient for this purpose. Also, Federal Rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.

I had the opportunity to ask questions and they have been answered; I understand all information contained in this document.

I voluntarily authorize the information specified above to be obtained from or released to PTP; it will be held in strict confidence. I understand my information cannot be re-released by a recipient without my written consent. I understand this authorization will remain in effect until I specify an expiration date. If I have questions concerning any of this content in the future, I will ask my clinician.

I release PTP from any legal responsibility that may arise from the release of the above requested information.
Client/Parent/Guardian Signature

Clear
Print Name
Date

MonthDayYear
Date
PTP Representative Signature & Credentials

Clear
Print Name & Credentials
Date

MonthDayYear
Date
ADMIN8-ENG–AUTHORIZATION RELEASE INFORMATION MEDICAL RECORDS REQUEST Revised 2/3/2022 PAGE 2 OF 2
Should be Empty:

AUTHORIZATION TO RELEASE INFORMATION MEDICAL RECORD REQUEST

IDENTIFICATION

PURPOSE OF RELEASE?

RELEASE DURATION

Important

Fees

Fee Exceptions

Redistribution of Confidential Information is Prohibited