Atara Health Solutions Release of Information

12011 Route 50, #410, Fairfax, VA 22033

(571) 535-2480 FAX (571) 533-1382

This consent is for disclosure of protected health information for purpose of treatment, operations or payment.

I understand that Atara Health Solutions may need to use and disclose information about my health or medical problems for the purposes of arranging, conducting, or referring for my treatments, for obtaining payment for the services rendered me and for the operations of the practice. I consent to the use of my information for the purposes of treatment, payment and health care operations.

I understand that my consent is not needed if the law requires Atara Health Solutions to report some aspect of my protected health information to a government agency. Examples would include suspected abuse, communicable disease and potential for serious bodily harm to myself or others.

I understand that I have the right to review the Atara Health Solutions privacy notice, to request restrictions on the use of my information and to revoke my consent at a later date.

I understand that if I withhold consent for the use of my information for the purposes of treatments, payment or operations, Atara Health Solutions may decline to undertake my care.

Psychiatric evaluations, progress notes, lab results, and other medical information may be disclosed.

Information released may include specifics about my past or current substance use, misuse or abuse, including diagnoses, treatment, substance(s) used, prognosis, etc.

Patient Name*

Patient Birthdate*

Patient Email*

Patient Phone Number*

Patient Address*

Will this form be Cosigned by another person, such as parent, guardian or healthcare power of attorney?*

YesNo

Name of Cosigner*

Suffix

What is the Cosigner's relation to the patient?*

Parent who is Legal GuardianOther Legal GuardianHealthcare Power of AttorneyOther

Cosigner Address*

Street Address Line 2

Cosigner Phone*

Cosigner Email*

I hereby authorize Atara Health Solutions, its employees, representatives and any other persons performing services for them or on their behalf to release any relevant personal and protected health information (PPI, PHI) to the entity or person below; I also authorize the entity below to share information with Atara Health Solutions:

Person/Organization to Share/Receive Information*

Who is to share information to/from Atara Health?

Address of Person/Organization to Share/Receive Information*

Phone Number*

Please enter a PHONE number

Fax Number

Please enter a FAX number.

Relationship of Above Person/Entity to Patient:*

Parent or Family MemberHealthcare Power of AttorneyMedical Provider (e.g., Primary Care Provider or Specialist)Psychologist, Psychotherapist or CounselorHealthcare Facility (Hospital, Residential Center, etc)FriendOther

I have read (or have had read to me) this authorization, and I agree to its terms as indicated by my signature below. I am entitled to a copy of this authorization.

Signature of Patient (Patient must sign regardless)*

Signature of Cosigner*