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

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  • 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.
  • CONSENT FOR COMMUNICATION:

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

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  • CONSENT FOR COMMUNICATION:

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

       *   *      *   

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

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  • RELEASE FOR MEDICAL OR FINANCIAL RECORDS

  • I authorize Gardenia Cove Mental Health, P.C. to release my records to the following person/organization:

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  • 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.

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