NCHH - Auth for Release of Info

NCHH - Authorization for Release of Information

- complete this form to allow us to send or receive protected health information -
Name of the Patient*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email of patient or parent/guardian completing this form
example@example.com

Is the patient under 18 years old?*

YesNo
Name of Parent/Guardian

First NameLast Name
I, hereby, give my permission to clinicians and staff at Nashville Center for Hope & Healing to share information as I have noted below. This release includes but is not limited to the following clinicians: Michelle Cochran MD, Kelly Anderson PMHNP, Leah Bowen PMHNP, Lisa Everhart, DNP, PMHNP, Lauren Valencia LCSW, Frances Perkins, LPC-MHSP, and Michael DeMarco, LPC-MHSP.
To whom are we disclosing, obtaining information, or both disclosing and obtaining information?

Enter the Name of the Physician, Clinician, Entity/Agency, Therapist, Specialist or Person including Address, phone, & fax number to whom we are disclosing your personal health information, or the Name of the Physician, Clinician, Entity/Agency, Therapist, Specialist or Person including Address, phone, & fax number from whom we are requesting information:
Name of Physician | Clinician | Entity/Agency | Therapist | Specialist | or Person*

First NameLast Name
Address of the Physician | Clinician | Entity or Agency | Therapist | Specialist | Person

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Please select if you are authorizing our company to both disclose and obtain information (give and receive) or if you prefer a one-way release :*

I am. both, consenting for you to disclose information (give information) AND to obtain information (get information), to and from, the person or entity noted aboveI am consenting, only, for you to obtain information (get information) from the person or entity noted aboveI am consenting, only, for you to disclose information (give information) to the person or entity noted above
SELECT WHICH INFORMATION YOU WANT TO BE SHARED:*

My mental health record in its entirety (including any substance use records & pharmacogenetic findings)Only specific information as designated below
If not your entire record and only some information is to be shared, select which part(s):

Diagnosis and TreatmentSubstance Use EvaluationMy substance use record in its entiretyA Summary of care including medications, diagnosis, and care renderedSummary of Treatment Recommendations/ Treatment PlanHospital or Partial Hospital RecordsIntensive Outpatient Program recordsProgress ReportsAttendance ReportsLaboratory DataPharmacogenetic Testing ResultsMedical history, diagnoses, medications, laboratory values, and any radiographic informationPsychological EvaluationPsychotherapy recordsOther
Select which form the information may be shared:*

AnyEmail onlyPhone onlyFax only
The purpose of this authorization for release*

Continuity of CareRequest history of prior careTransferring careCase managmentOther
This release shall be effective during the time the patient, is under the care of the clinicians and staff of the Nashville Center for Hope & Healing, or until I revoke it. I understand that there is a statutory privilege that prohibits disclosure of communications between a patient and psychiatrist in Tennessee, and I hereby waive this privilege with regard to this release. I may revoke this consent at any time except to the extent that the release has been completed.

By signing below I acknowledge that I have read the foregoing release and selected the options I desire, and I understand its contents. I am at least eighteen (18) years old and fully competent to give my consent for this release of patient information.
Signature*

Clear
Full name of Person signing*

First NameLast Name
This information has been disclosed to you from confidential records of which may be protected by federal and/or state law. Federal Regulation prohibits you from any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or otherwise permitted. A general authorization for the release of medical or other information is not sufficient for this purpose.
Do you have another release to complete?

YesNo
Should be Empty:

NCHH - Authorization for Release of Information