Patient Intake Form

This form when completed and signed by you, authorizes the release of protected health information from your clinical record to the doctor/facility/therapist you designate.

Patient Name*

First NameLast Name

Birth Date*

MonthDayYear

I authorize Medpsych Intergrated PLLC to Obtain OR Release records from/to the following providers listed below*

Obtain FromRelease to

Practice/Clinic name , address, phone and Fax number (only entity per form)*

Information allowed to be released:*

Purpose of this release:*

I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by a recipient of such information and it is possible that once disclosed, the privacy of the information may no longer be protected under federal medical privacy law. I understand that this authorization gives permission to release the information above which may include drug/alcohol abuse, treatment, and psychological or psychiatric impairments, HIV/AIDS or physical conditions. A fee may be charged for copying the protected health information.

Signature*

Date

Release of Protected Health Information