Primary Care Release

Pinnacle Behavioral Health IPA LLC
2018-19 Primary Care Release
Pinnacle Behavioral Health IPA, LLC

10 McKown Rd Albany, NY 12203
Name

First Name Last Name
Date of Birth

- Month - Day Year
Authorize my Healthcare Information to be:

Released To: Obtained From:
Physician

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number
Fax Number

- Area Code Phone Number
Specific Items ex. Labs, Progress Notes, Medical History
I understand that I have the right to revoke this authorization at any time by submitting a revocation in writing to the medical records department. The revocation will not apply to information that has already been released in response to this authorization. I also understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. This authorization will expire one year from the date of the signature below and may be used until such time for a one time release or periodic release of information. If the disclosure is for educational purposes I understand that the recipient may be my child's home school district and any school within the home district. Disclosure to any other school or educational entity requires a separate authorization. I understand that authorizing the disclosure of this information is voluntary. I understand I can refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment. I understand that I have a right to receive a copy of this authorization. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the recipient, and the information may not be protected by the Federal privacy rules or by New York State Law. I further understand that my records are protected under federal regulations governing confidentiality of alcohol and drug abuse patient records, 42 cfp part2, and New York State Mental Hygiene Law section 33.13 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. *Signature (under 18 requires guardian signature):

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Date

- Month - Day Year
If you agree to disclose information, please skip to end and click "submit"
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Pinnacle Behavioral Health IPA LLC

2018-19 Primary Care Release

Pinnacle Behavioral Health IPA, LLC