Release of Information Form | Trinity Psych Wellness

Release of Information Consent Form

Please complete this form to the best of your ability.

Release of Information

TRINITY PSYCH WELLNESS

Authorization for Release of Health Information

First Name

Last Name

Date of Birth: Day/Month/Year

Your Email

The above named person must indicate when this authorization permission is to expire:

The person named above is currently OR has been previously a patient of:

Address of Provider / Facility named above:

Address Line 1

Address Line 2

City

State

Zip Code

Country

Provider's Phone

Provider's Fax

The patient/client above hereby authorizes

authorizes name provider to:

Request health information

Send health information

Discuss health information

Name of Person, Provider, or Facility Address to release information.

Provider's Phone

Provider's Fax

SCOPE

Of patient/client information

All information regarding assessment, diagnosis, and treatment of patient’s condition, concern, or disease (specify details as needed):

Start Date

End Date

Any other comments to communicate place here.

AUTHORIZATION

Name of Patient or Authorized Representative

First Name

Last Name

Signature of Patient or Authorized Representative

Sign Here

Today's Date - select

Signature of Witness

Sign Here

Today's Date - select

If not signed by the patient, indicate relationship of authorizing person to patient:

Additional Authorization

Certain information is covered by additional protection and requires specific authorization. To authorize release or discussion of the following type of information, the person named above must initial and date each item. If an item is not initialed and dated, the information, if such information exists, cannot be released or discussed.
Select information types that apply and specify the date range of additional authorization release period.

I authorize release or discussion of the following type of information: (Select all that apply)

Alcohol or Drug Use/Abuse Treatment

Mental Health Treatment

HIV Status or Treatment

FROM Date

TO Date

PERSONAL RIGHTS

The above-named person has the following rights:

This authorization is effective for the above requested and authorized health care information only. You may ask for and receive a copy of this authorization form.

This authorization will expire on the date you indicated above. Additionally, you may revoke this authorization at any time by submitting a written request to this clinic or caretaker. Your revocation will be honored except to the extent that is been acted upon in good faith while in force.

You have the right to inspect the information you are authorizing to be re-released. This and other specific rights regarding the handling of your health information are outlined in our Privacy Practices document.

The information you are authorizing to be released could be re-released or disclosed by the recipient. Such additional disclosures or releases may not be prohibited by law. We are not responsible for the actions of others who may be provided with information released as a result of this authorization.

You may refuse to sign this authorization. Such refusal will not affect your ability to obtain treatment except to the extent that the information being requested may assist your health care provider in determining appropriate treatment. Your refusal to sign this authorization will not affect your eligibility for benefits.