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 NP, Leah Bowen NP, Lauren Valencia LCSW, Ali Self LMSW, Frances Perkins, LPC, and Michael DeMarco, LPC-Temporary.
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:
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.
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.