Client Name:   First Name*   Last Name*   Date of Birth* 

MEDICAL  

Authorization and Consent for Release of Information

WHO
By signing below, I authorize Thrive Behavioral Health and staff members to release and receive written and or/verbal information related to the client listed above to the person or agency indicated below:

Please Enter Primary Care Provider information below:
To and From (name of PCP) :   name of PCP*
Phone:     Phone number    
Fax:   Fax number      
Address (if available):   Street Address   Address Line 2   City   State   Zip   
Dates of Service: Any and all, unless indicated here:   Date of Service   

WHAT
I specifically authorize the exchange of the following information:
✔ Medical Records   
✔ School and educational records   
✔ Verbal discussion of case (including, but not limited to diagnosis, attendance, treatment progress, interventions, psychosocial history, and recommendations).   
✔ Mental Health Records including Evaluations, Individualized Treatment Plans, and Medication History   
✔ Information related to and/or including substance use, substance abuse history, assessment, treatment, progress and referrals  
✔ Information related to and/ or including HIV, AIDS, or other STD related information      
Other:       

WHY
✔ Continuity of Care/Treatment coordination   
Client or Parent/ Legal Guardian's request   
Legal purposes   
Other:       

Important Information
I understand that:

• This authorization is voluntary. My treatment will not be impacted if I do not sign this authorization. I do understand that Thrive psychiatrists or nurse practitioners are not required to prescribe medication if they determine they do not have enough information in order to make an informed medical decision.
• This authorization is valid 1 year from date signed unless otherwise indicated and specified here:     .
• I may revoke/withdrawal this authorization, except to the extent that action has been taken prior to receipt of the revocation/withdrawal, by notifying Thrive in writing of withdrawal of authorization to release information.
• Once my health information is exchanged/released, it may no longer be protected by federal law and could be disclosed by the person(s) receiving it.
• The medical information released may contain information related to HIV status, AIDS, sexually transmitted diseases, mental health drug and alcohol abuse, etc.

Today's Date*   
Signature*   
Signature of Adult Client or Parent/Guardian of Minor or Client