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 you do not have a Primary Care Physician, click the button that says "I do not have a Primary Care Physician" and continue with the rest of the form.)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Do you have a Primary Care Physician?*

YesNo
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
Bariatric Physician/Center's Name:*
Bariatric Physician/Center's Address:
Phone Number for Bariatric Surgeon/Bariatric Center:*
FAX NUMBER for Bariatric Surgeon/Bariatric Center:*
Please enter a valid 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/ALLDiagnosisMedication InformationAssessment InformationOther:
Please describe other information to be disclosed:
Purpose of such a disclosure:

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

Clear
Date

MonthDayYear
Date
Parent/Guardian Signature

Clear
Date

MonthDayYear
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