Spectrumbehavioralhealthny.com-Consent To Release/Receive Information to/from PCP

SPECTRUM BEHAVIORAL HEALTH

New In-take Fax: 845-485-8780

Poughkeepsie Fax: 845-452-7546 / Fishkill Fax: 845-897-3376 / Kingston Fax: 845-331-1479
Informed Consent To Release/Receive Information For Your Primary Care Physician
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Patient Social Security Number*
I hereby give permission to Spectrum Behavioral Health to release/receive information to/from:
My Primary Care Physician's Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Or choose one of the following options:

I do not have a Primary Care PhysicianI do not want to involve my Primary Care Physician
My Primary Care Physician's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number
This information is needed for coordination of care between you and your Primary Care Physician, Spectrum Behavioral Health, and for other issues concerning your care:
My consent is subject to revocation at anytime (except to the extent that action has been taken in reliance on my consent) and expires in 1 year unless an earlier date is specified.
Date of Revocation if earlier than 1 year from the date signed:

MonthDayYear
Signature*

Clear
Date*

MonthDayYear
Note

For persons receiving treatment for alcohol or drug abuse, any information disclosed as per this release is protected by Federal Law. Federal Regulations (42 CFR Part 2) prohibit any re-release or further disclosure of information without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.
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Informed Consent To Release/Receive Information For Your Primary Care Physician