GC Release of Information Form

Gardenia Cove Mental Health, P.C. Release of Information Form
Please select from the following options:*

I am the patient completing this Release of InformationI am the patient's personal representative completing this Release of Information
Representative's Name* , Relationship to Patient*
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
While not required, we highly recommend you complete a release of information for your primary care physician, especially if they referred you to our practice. This will help your health care team work together to provide consistent, quality care.
I would like to complete the following type(s) of Release of Information Forms*

Consent for Communication (ideal for family, friends, and other physicians/health care providers)Consent for Records Release Only

CONSENT FOR COMMUNICATION:
I authorize the providers and staff of Gardenia Cove Mental Health, P.C. to communicate with the following person/organization:

Full Name of Person or Organization* Relationship to Patient* Phone Number*
Gardenia Cove Mental Health, P.C. may contact the above person/organization regarding: (check all that apply)*

Appointments/SchedulingBilling/Insurance MattersHealth and/or Medication ConcernsPatient Health Records (important for other health care providers)ALL OF THE ABOVE
Is there another person or organization you would like us to be able to communicate with?*

YesNo

CONSENT FOR COMMUNICATION:
I authorize the providers and staff of Gardenia Cove Mental Health, P.C. to communicate with the following person/organization:

Full Name of Person or Organization* Relationship to Patient* Phone Number*
Gardenia Cove Mental Health, P.C. may contact the above person/organization regarding: (check all that apply)*

Appointments/SchedulingBilling/Insurance MattersHealth and/or Medication ConcernsPatient Health Records (important for other health care providers)ALL OF THE ABOVE
Is there another person or organization you would like us to be able to communicate with?

YesNo

I authorize the providers and staff of Gardenia Cove Mental Health, P.C. to communicate with the following person/organization:

Full Name of Person or Organization* Relationship to Patient* Phone Number*
Gardenia Cove Mental Health, P.C. may contact the above person/organization regarding: (check all that apply)*

Appointments/SchedulingBilling/Insurance MattersHealth and/or Medication ConcernsPatient Health Records (important for other health care providers)ALL OF THE ABOVE

RELEASE FOR MEDICAL OR FINANCIAL RECORDS
I authorize Gardenia Cove Mental Health, P.C. to release my records to the following person/organization:

Representative's Name* Relationship to Patient* Phone Number*

Secure Fax Number*
I would like the following records sent:*

ALL Medical RecordsALL Financial RecordsOther
My protected health information described above is to be released for the following purposes:
Ex. life insurance, disability determination, at the request of patient or parent, transfer of care, etc.

I hereby authorize the providers and staff of Gardenia Cove Mental Health, P.C. to communicate and/or send records to the individuals and/or organizations that were entered on this form.

I understand that the records described above may contain information relating to sexually transmitted disease, HIV/AIDS, notable diseases, alcohol and drug abuse treatment and/ or mental health, and I specifically authorize the release of this information.

I understand that Gardenia Cove Mental Health, P.C. cannot condition treatment, payment, enrollment, or eligibility of benefits on the signing of this authorization. I understand that I may revoke this authorization by sending written notice to Gardenia Cove Mental Health, P.C.. However, I understand that any revocation will not be effective as to any action in reliance of the authorization prior to receipt of the written revocation.
Patient or Personal Representative Signature*

Clear
Date of Signature*

MonthDayYear
I would like this Release of Information to expire:*

One year from today (maximum time Release of information can last)ONE TIME ONLYOther
Should be Empty:

Gardenia Cove Mental Health, P.C. Release of Information Form