Release form with Copay

Patient Full Name (First Last) *

Email (Test results, receipts, and forms will be sent to this email address):

Confirmation Email example@example.com

If you would like to pay any past or upcoming copays, but don't know the amount, please call 205-329-7815 from 8am-noon or from 1pm-4pm to find out what you owe.

If you know your past balance due, or your upcoming appointment copay, then please enter the amount here:

USD Please enter your copay amount here

Enter Firstname, Lastname, Credit Card Number, Security Code, Expiration, and Credit Card Zipcode
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Birth Date *

Date

Social Security Number

Birth Date

Date

When we ask doctors to send us your records, what years should we request?

Do you have detailed restrictions you insist on adding about releasing information?

No, I do not need to specify additional detailed restrictions. Yes

Please list any restrictions on this release of information (you must also speak to someone in our office and verify that providers, and especially that staff understand and are able to agree your restrictions):

I hereby authorize Dr. Azrin, Dr. Millsaps, or Leslie Kahn to obtain and to release my information to the following people, doctors, or facilities:

1st) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization): *

Phone (if you know it)

Fax (if you know it)

Address (if you have it)

City

State

Zip

Is there a 2nd individual or organization that we need to get or give information to?

Yes No

2nd) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization):

Phone

Fax (if you have it)

Address (if you know it)

City

State

Zip

Is there a 3rd individual or organization that we need to get or give information to?

Yes No

3rd) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization):

Phone

Fax (if you have it)

Address (if you know it)

City

State

Zip

Is there a 4th individual or organization that we need to get or give information to?

Yes No

4th) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization):

Phone

Fax (if you have it)

Address (if you know it)

City

State

Zip

Is there a 5th individual or organization that we need to get or give information to?

Yes No

5th) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization):

Phone

Fax (if you have it)

Address (if you know it)

City

State

Zip

Release Agreement: This form, when completed and signed by you, authorizes me to release, as well as obtain, protected information from your clinical record to and from the person(s) you designate. I hereby authorize Dr. Azrin, Dr. Millsaps, Leslie Kahn, Dr. Yarbrough, and/or his or her administrative and clinical staff to release any and all contents of my chart (including at least billing information, psychotherapy/progress notes, test results/data, reports, visit information, prescriptions, medical information, documents provided by patient, insurance/third party forms/reports, records received by others). This information should only be released to and/or obtained from the above individuals. I am requesting my psychologist, psychiatrist, or social worker release this information to aid in treatment and/or assessment and/or provide information about me to others. This authorization shall remain in effect indefinitely. However, you have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that my psychologist, psychiatrist, or social worker generally may not condition psychological services upon my signing an authorization unless the services are provided to me for the purpose of creating health information for a third party. I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule. I hereby release the above treatment/assessment providers and their respective staff and office from any and all liability and claims arising out of or relating to the disclosure and/or release of confidential and/or privileged information.

Informed Consent: I agree to participate in evaluation/treatment, and the purpose has been explained to me and/or my guardian/representative.

Name of patient and/or responsible party signing below:

Signature of patient or responsible party *

Clear

Date

Date Hour Minutes AM/PM Option

If signed by patient's representative, please provide a description of representative's authority to act for the patient:

Release of Information