Bariatric Coordination of Care Consent Form

COORDINATION OF CARE CONSENT FORM
I authorize The Center for Psychological Well-Being PLLC to release and/or obtain confidential information contained in my patient record to and from the following physician(s): (If no Primary Care Physician, click the button that says "I do not have a Primary Care Physician" and sign below
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Do you have a Primary Care Physician? *

Yes No
Please confirm that you do not have a Primary Care Physician.

I do not have a Primary Care Physician
Primary Care Physician's Name
Primary Care Physician's Address
Primary Care Physician's Phone Number
Do you have a Bariatric Physician or Center? *

Yes No
Please confirm that you do not have a Bariatric Physician or Center.

I do not have a Bariatric Physician or Center
Bariatric Physician/Center's Name
Bariatric Physician/Center's Address
Bariatric Physician/Center's Phone Number
Others I wish information to be disclosed to (if any):
Name of person to disclose information to
Relationship to patient
Name of person to disclose information to
Relationship to patient
Information to be disclosed (please check all appropriate boxes)

ANY/ALL Diagnosis Medication Information Assessment Information Other:
Please describe other information to be disclosed:
Purpose of such a disclosure:

Coordination of Care Other:
Please describe other purpos(es) for such disclosure(s):
Client Signature

Clear
Date

Month Day Year
Date
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
The use of this consent by The Center for Psychological Well-Being is effective for one year from the date of signature, and may be revoked by myself, in writing at any time. This consent is being signed voluntarily and under no circumstances is a precondition of treatment.
Should be Empty:

COORDINATION OF CARE CONSENT FORM