Client Name: First Name* Last Name*
MEDICAL
Authorization and Consent for Release of Information
WHOBy 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 WHATI 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 InformationI understand that:
Signature* Signature of Adult Client or Parent/Guardian of Minor or Client