Opt-out of Initial Primary Care Physician Contact
by Mid-Atlantic Behavioral Health
At Mid-Atlantic Behavioral Health we are devoted to being proactive in ensuring you get the best possible behavioral healthcare. As part of this effort we would like to initiate contact with your primary care physician in order to coordinate care if needed or desired. We understand that some individuals may prefer that we do not initiate contact with their primary care physician. If your choice is not to allow Mid-Atlantic Behavioral Health to initiate contact with your primary care physician then please fill out this form.
I choose not to have Mid-Atlantic Behavioral Health initiate communication with my primary care physician. I understand that this may prevent important information from being confidentially examined by my primary care physician that may be relevant to my health.
Upon signing this form I also understand and adhere to the regulations stated in the Provider-Patient Services Agreement about the limits of confidentiality, which in specific situations Mid-Atlantic Behavioral Health is required to speak with my primary care physician. This includes, but is not limited to, insurance regulations, court proceedings, government regulations, lawsuits, as well as, situations in which we are legally obligated to take action. For more specifics please refer to the Provider-Patient Services Agreement.
It is also understood that I may revoke this form at any time by signing the Consent for Release of Information form. I also acknowledge that once I have signed the Release of Information form, this Opt-out form shall be nullified.