Representative's Name* , Relationship to Patient*
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*
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 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.