haelanhealth.com - Release of Information Consent Form

Today’s Date

Date

Patient’s Full (Legal) Name

First NameMiddle NameLast Name

Patient’s Date of Birth

Date

Guarantor / Guardian’s Relationship to Patient

SelfParentLegal Guardian / Power of Attorney

By signing this form, I am authorizing that confidential medical, psychological, and/or psychiatric information can be released to and/or discussed with the people or agencies listed below unless noted by exclusions or limitations. This form is signed voluntarily and may be revoked at any time. All disclosures made pursuant to this form are valid as long as they were made before the date of revocation.

I hereby authorize: (Full Legal Name of person or facility for whom you would like to grant authorization within your medical records).

Contact phone number: (Of person whom you are granting authorization within your medical records.

Please enter a valid phone number.

Other contact details of a person or facility: (email, fax number, mailing address, etc.)

Name and contact information for other facility

I hereby authorize the release of my medical, psychological, and/or psychiatric mental health information to / from:

Haelan Psychiatry & Wellness
5309 West Village Parkway, Suite 3
Rogers, AR 72758
Office phone: (479) 275-4152
Fax: (479) 227-6811

Type of Information to be Disclosed

I authorize disclosure of all health information, including medical, pharmacy, mental health, substance abuse, and psychotherapy from (effective date) to the present date.My health information is disclosed at my request or at the request of my personal representative.

I authorize only the disclosure of the following information

Purpose of Disclosure: Continuation of medical and/or mental health/psychiatric care

I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is not dependent on my signing this authorization. By signing below, I acknowledge that I have read and understand this document and that I have voluntarily given my provider authorization to disclose my records. I understand that I may revoke this authorization at any time by providing a written notice to my provider. However, I understand that the revocation will not have an effect on any actions taken prior to the date my revocation is received by the provider. I understand that my information may be redisclosed by the authorized person/organization receiving the information and that, at any point, the information may no longer be protected under the terms of this agreement. This authorization will expire one year following the date signed unless revoked in writing.

Patient or Guarantor Full Name (Legal Name)

Signature

Date Signed

Date