VPC Release of Info Consent Form

Authorization to Obtain/Release Confidential Information Consent
(Patient Name)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I , First Name Last Name ,am the patient or legal representative and authorize the Virtual Psychiatric Care Provider to
Choose 1*
Name of Person, Organization or Practice Name*
Relationship*
Organization Medical Records Contact Number*
Organization FAX Number (Release VPC records to)*
Please enter a valid phone number.
Secure Email Address (Email VPC records to):
example@example.com
RETURN MEDICAL RECORDS TO SECURE FAX NUMBER: 954-278-9083 or Email records: Billing@VirtualPsychiatricCare.com
Description of Information to be Disclosed*

All Mental Health RecordsPrognosisMedication ListPsychiatric EvaluationPresence in TreatmentToxicological Reports/Drug ScreenProgress NotesTreatment Plan or SummaryOther:
Exceptions/Information Not To Be Disclosed if requested
Purpose

The purpose of this document is to allow access to information necessary to improve assessment and treatment planning, share information relevant to treatment and, when appropriate, coordinate treatment services. For other purposes, please specify:

Expiration

Unless sooner revoked, this consent is valid for a period of 12 months after consent is obtained.

Conditions

I understand that Virtual Psychiatric Care will not condition my treatment on whether I give authorization or obtain authorization for the requested disclosure. The consequences of refusing to sign this authorization have been explained to me.

Form of Disclosure: Unless you have requested in writing that disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner we deem to be appropriate and consistent with applicable law, including but not limited to verbally, in paper format, or electronically.

Form of third party Request: All requests for patient information must be submitted in writing via email, fax, or paper format.

RE-DISCLOSURE

"This information has been disclosed to you from records protected by Federal Confidentiality rules (42 CFR part 2 The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information in NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse Client."

I may request a copy of this authorization for my records.

RIGHT TO REVOCATION

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to MiamiPsych Concierge, LLC (Dba "Virtual Psychiatric Care"). I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

Patient or Legal Representative Signature:
Signature*

Clear
Date*

MonthDayYear
Date
Records Release To Virtual Psychiatric Care Instructions:

1. PLEASE RETURN MEDICAL RECORDS TO SECURE FAX: 954-278-9083.

2. OR EMAIL: Billing@VirtualPsychiatricCare.com

3. Or Mail To: Virtual Psychiatric Care: Address: 1900 N Bayshore Dr, ste 1A #144, Miami, FI 33132. Contact Number 786-761-1155:
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Authorization to Obtain/Release Confidential Information Consent