• Client Name:   *   * 

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  • 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) :   * 
    Phone:         
    Fax:         
    Address (if available):                  
    Dates of Service: Any and all, unless indicated here:      

    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      
               

    WHY
    ✔ Continuity of Care/Treatment coordination   
       
       
          

    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.

  • *   
    Signature of Adult Client or Parent/Guardian of Minor or Client

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