NC Psychological Consultants, PLLC

North Carolina Psychological Consultants, PLLC

8510 Six Forks Road

Suite 104

Raleigh, NC 27615

Fax Number: 919-615-3331

Phone Numbers:

919-745-7348 Dr. Cynthia Hernandez

919-741-0343 Dr. Andres Hernandez

This form, when completed and electronically submitted by you, authorizes your North Carolina Psychological Consultants' clinician to release/disclose protected clinical information from your record with the person or agency that you designate below. You may also authorize that person or agency authority to release protected clinical information to North Carolina Psychological Consultants. The exchanged information may include verbal, electronic or written information.

Name of Patient

First NameLast Name

Date of Birth

MonthDayYear

I, whose name and date of birth appear above, authorize my assigned North Carolina Psychological Consultants's clinician to exchange relevant clinical information regarding me and my clinical record with the person/agency listed below.

Release of information from North Carolina Psychological ConsultantsThe release of information from the Person or Agency listed belowBoth. I authorize the exchange of information between North Carolina Psychological Consultants and from the Person or Agency listed below

Name of person or agency with whom clinical information is to be exchanged

First NameLast Name

Fax Number of the person or agency with whom clinical information is to be exchanged

Area CodeFax Number

Email person or agency with whom clinical information is to be exchanged

example@example.com

Address of Person or Agency with whom clinical information is to be exchanged

Street Address

Unit/Apt. #

CityState / Province

Postal / Zip Code

Phone Number of the person or agency with whom clinical information is to be exchanged

Area CodePhone Number

I understand that I may rescind this Release of Information at any time by providing written notification to North Carolina Psychological Consultants and that, unless otherwise specified, this Release will be valid for one year from the date it was received.

I also understand that clinical information released pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by HIPPA privacy rules, for which North Carolina Psychological Consultants is not responsible.

Today's Date

MonthDayYear

Signature