Release of Information Authorization

Release of Information Authorization
Name of Patient:
Patient DOB:
Patient Phone:
I authorize Sacred Psychiatric Services to release/obtain/exchange information with:
Name/Organization name:
Phone:
Email
Address (if available):
Relationship to patient:
Check all that apply:
- Dates of treatment
- Medical information, including my symptoms, diagnosis, medications, and treatment plan
- Behavioral health information, including substance dependency, including my symptoms, diagnosis, medications, and treatment plan
- Labs/tests/diagnostic results
- Billing and payment information
- Other
Other
This consent will expire 1 year after the date of my signature as it appears below.
I understand that by signing below, I am authorizing the release of all or part of my medical record for the purpose of my treatment and/or pertinent healthcare operations. This release may include records containing information regarding the diagnosis and/or treatment of mental illness, and/or drug and/or alcohol addiction or abuse to any person/persons and/or agency noted above. I also understand that I have the right to revoke this release in writing at any time.
Patient Name:
Today’s date:
Signature of Patient:

Medical Disclaimer:

This website is not intended to offer medical or psychiatric advice. The content, including tests, blogs, graphics, images, videos, and other materials presented here, is purely for informational purposes. None of the content on this site should be viewed as a replacement for professional medical or psychiatric advice, diagnosis, or treatment. It is essential to consult with your physician or another qualified healthcare provider for any inquiries regarding medical conditions or treatments, and before starting a new healthcare regimen. Never ignore or delay seeking professional medical or psychiatric advice due to information found on this website. It’s important to note that Nurse Practitioners in this practice work with collaborating psychiatrist.

Release of Information Authorization

Release of Information Authorization

I authorize Sacred Psychiatric Services to release/obtain/exchange information with:

This consent will expire 1 year after the date of my signature as it appears below.