Authorization for Use or Disclosure of Protected Health Information

Cornerstone Psychiatric Services, Inc.

David Donahue, D.O. ◊ David Fawks, APRN ◊ Smitha Ajesh, APRN ◊

Lenice Haber, LCSW ◊ Nancy Stetter-Coblentz, LCSW

1790 E. Venice Ave. Ste. 204 Venice, FL 34292

Phone: (941) 488-8884 Fax: (941) 375-0119
NOTICE
- Age Limit: our practice only accepts patients 18 years of age and older
- Our providers DO NOT prescribe or manage Suboxone (buprenorphine and naloxone) or Clozoril (clozapine)
- Our practice does not accept cases related to: workers compensation, auto accident, personal injury, court order psychiatric evaluations or pre-surgical psychiatric evaluations.
If any of the 3 above conditions are valid to you, unfortunately we will not be able to proceed as a patient in our practice. Please seek other mental health providers in the area.

_______________________________________________________

Who needs to complete this form? See the reasons below:

1.) All new patients, we suggest and encourage you to complete this form for your Primary Care Physician (PCP) and your previous mental health provider (psychiatrist, APRN, psychologist, and therapist). One form per provider. Complete additional Online forms to include your spouse or any individual(s) you allow to be able to call our office and ask/discuss information relating to your appointments, prescriptions and treatment.

2.) If you have recent lab order results from your PCP, please complete with your PCP contact information.

3.) If you have been asked by our office staff to complete this form.
Authorization for Use or Disclosure of Protected Health Information
Patient’s Name:*

First NameLast Name
Date of Birth*
CPS Medical Record Account #: (Ask CPS staff for your acct#, if not known. You can leave blank if you don’t have it available)
I, the patient named above, hereby authorize Cornerstone Psychiatric Services, Inc., to release to and/or obtain from contact name listed below, in any form or format, my protected health information/records, which may include treatment of drug abuse, child abuse, AIDS, alcoholism or mental illness. This authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C Section 132d, and regulations promulgated thereunder, as amended from time to time (collectively referred to as "HIPAA").
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient Phone Number*
Please check option below: (The default is set to both checked)*

✔️Authorize Cornerstone Psychiatric to release to the person, provider or facility named✔️Authorize Cornerstone Psychiatric to Obtain from the person, provider or facility named
Please read carefully !!!

The next field should not have your name in it.

Generally, the name should be your Primary Care Provider (PCP) name or other provider name that we are sending and/or requesting records; or patient spouse or family member name and contact phone number to allow us to communicate with them about your treatment/care.
You are authorizing release to/from this name: Type in ONE name (Either name of your Primary Care Provider (PCP), other provider, facility name , spouse name or any individual person you are authorizing this release for:*
Alert: Some devices have autofill and may auto-populate your patient name here, if this occurs make sure to change this to be the PCP or other provider name we are obtaining and/or releasing medical records.
This person or facility named above is my:*

Primary Care Provider (PCP)Mental Health ProviderNeurologistCaregiverParentSpouseSelfOther
Provider / PCP / Facility /Spouse Name or Individual Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
This should be Provider/Facility contact phone number OR your spouse phone or the person you are authorizing phone number. Some devices may have autofill and may fill in wrong number here. Please correct as needed.
2nd / Alternate Phone Number:
(Optional)
Fax Number:
This should be Provider/Facility Fax number. Some devices may have autofill and may fill in wrong number here. Please correct as needed.
PURPOSE OF DISCLOSURE (Please check one):*

Continuity of Care and/or Coordination of Care (select this for to/from another provider, clinician or facility)Disability case / reasonLegalOther
INFORMATION TO BE DISCLOSED (please check one or more from the check boxes below):*

✔️ As stated in the requested abstract below, unless specified in the next option with specific date rangeSpecific Date range from/to as specified below
From Date:
To Date:
Select Abstract options or one of the other options.*

HOSPITAL Abstract (most recent stay)—includes,as applicable, Discharge Summary, Discharge Medication List, History & Physical,, Operative/Procedure Report(s), Consultation Report(s), and lab/other test result(s)MENTAL HEALTH Abstract—includes Initial Evaluation, last three office progress notes/psychotherapy notes, most recent lab results and medication list; additional recordsmay be released/requested after this initial request up until this Release of Information “ROI” expires.Laboratory Results (most recent only); additional lab results may be requested after this initial request up until this ROI expires.PCP/CLINIC Abstract—includes, as applicable, MOST RECENT OFFICEVISIT ONLY, Summary Lists, Medication Lists, and lab/other test result(s); Additional records may be requested after initial request up until this ROI expires.Complete record for all dates of service until ROI expiresVerbal communication as needed until ROI expiresDischarge Summary with medication listGenetic Testing resultsLast Progress Note / Encounter Note onlyPsychological Testing reportOther
I understand that disclosure of the information in this medical record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV It may also include information relating to behavioral or mental health services or psychiatric treatment, treatment for substance abuse, or genetic test results.

I understand that once the information is disclosed, the information is subject to re-disclosure and may no longer be protected by the federal privacy regulations. This form may be revoked at any time providing the information has not already been disclosed. I have the right to revoke this authorization at any time. Revocation must be made by notifying, in writing, the Privacy Officer, 1790 E Venice Ave. Ste. 204, Venice, FL 34292.

I understand that this authorization will be in force and effect until the day I revoke this permission or (7) seven years from date signed below, whichever occurs first, unless otherwise specified on the following date/event/condition

I understand that my authorizing the disclosure/obtaining of this health information is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization. I understand that I may inspect or copy information to be used or disclosed as provided by law. Fees may be applied and billed by Cornerstone Psychiatric to me (patient) or if applicable to attorney, disability case vendor, insurance vendor or other vendor requesting such records. Fees are a $1.00 per page for pages 1-25 and $.25 for pages greater than 25. No fees applied when sending to /receiving from another provider of care for the purpose of Continuity of Care.

I understand the matters discussed on this form. I release the provider, its employees, officers and directors, medical staff members, and business associates from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein.
Signature (use your mouse or finger if you have a touchscreen)*

Clear
Date*

MonthDayYear
Date
If not patient signature then indicate this person role/authority to act on behalf of patient
Signature of Witness: (not required)

Clear
Please verify that you are not a robot*
Should be Empty: