Communication between Behavioral Health providers and your Primary Care Physician (PCP) is important to ensure that you receive comprehensive and quality health care. There are circumstances when your Behavioral Health condition and/or medications will influence treatment of your physical conditions. Many times behavioral health and physical health share a connection. This form will allow your Behavioral Health Provider to share Protected Health Information (PHI) with your PCP. This information will not be released without your signed authorization. This PHI will only include diagnosis, treatment plan and medication, if necessary. Information relating to any psychotherapy notes or conversations will not be shared.
I, the undersigned, understand that I may revoke this consent at any time. I have read and understand the information and give my authorization.