Authorization for Release of Medical Records

Authorization for Release of Medical Records (HIPAA Compliant)
Practice Information
Practice: MedPsych Integrated, PLLC

Address: 7780 Brier Creek Pkwy #306, Raleigh, NC 27617

Phone: 919-582-7272 Fax: 866-533-0016

Secure Email: info@medpsychnc.com
1. Patient Information
Patient Name*
Date of Birth*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
2. Authorization to Release Information FROM
Name:*
Facility/Practice:*
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
3. Authorization to Release Information TO
MedPsych Integrated, PLLCOther
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address
4. Information to Be Released
Psychiatric evaluationsMedication management recordsTherapy/progress notesPsychological testing resultsTreatment plansDischarge summariesLab resultsBilling recordsAppointment historyEntire medical recordOther
5. Date Range of Records
Type a question

All DatesSpecific dates
From*

MonthDayYear
Date
To*

MonthDayYear
Date
6. Purpose of Disclosure
Continuity of careReferral/consultationInsurance/claims processingLegal requestPersonal useDisability determinationOther
7. Sensitive Information (Initial Required)
I understand that the records may include sensitive information.
Please initial to authorize the release of:
Signature   Mental health records
Signature   Substance use treatment records
Signature   HIV/AIDS information
Signature   Genetic testing information
8. Method of Delivery
Secure emailFaxMailPatient portalOther
9. Expiration of Authorization
Date

MonthDayYear
Date
90 days from signature1 year from signatureUpon completion of request
10. Patient Rights & Acknowledgment
I understand that:

• I may revoke this authorization at any time in writing, except to the extent action has already been taken.

• Information disclosed may be subject to re-disclosure and no longer protected by HIPAA.

• I am entitled to a copy of this authorization.

• Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization (except as allowed by law).
11. Signature
Patient/Legal Representative Name: *
Relationship to Patient (if applicable):
Signature*
Date*

MonthDayYear
Date
12. Office Use Only
Date Received*

MonthDayYear
Date
Processed by:
Date Completed*

MonthDayYear
Date
Method sent:
Should be Empty:

Authorization for Release of Medical Records (HIPAA Compliant)

Practice Information

1. Patient Information

2. Authorization to Release Information FROM

3. Authorization to Release Information TO

4. Information to Be Released

5. Date Range of Records

6. Purpose of Disclosure

7. Sensitive Information (Initial Required)

8. Method of Delivery

9. Expiration of Authorization

10. Patient Rights & Acknowledgment

11. Signature

12. Office Use Only