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  • Cornerstone Psychiatric Services, Inc.

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

    Joan Flynn, LCSW  ◊  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. 

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    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
  • 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").

  • 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.

    Please make sure to remove your name if it appears in this field. 

    Thank you. 




  • 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.

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  • Reminder

    If you were completing the New Patient Intake Form, after you click SUBMIT for this release, then remember to go back to your New Patient Intake form to continue to Step 4.

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