Third Party Entities and Subpoena Agreement Contract
1. Right Track Medical Group will submit medical records to any 3rd party as long as there is an Authorization for the release of protected health information sign by the patient/legal guardian.
2. Right Track Medical Group providers (physicians, nurse practitioners, and therapist) DO NOT participate in any Short Term Disability Claims, Long Term Disability Claims, Family Medical Leave Act (FMLA), Child Custody Cases, Divorce Cases, Workers Compensation Claims, Health Questionnaires, Return to work Statements, or any other 3rd party requesting information to be submitted outside of electronic medical records.
3. Furthermore if at any time your provider or providers are subpoena to appear in court for you or a case related to you, this will immediately terminate your therapeutic relationship with the provider or providers. At this time you would be referred to another provider outside of Right Track Medical Group to continue your mental health treatment. You will also be responsible for the professional hourly rate of any Right Track Medical Group employee that is required to provide testimony in a court case.
I understand the above agreement contract.