Menciagomez@1 - Consent for Release of Information

MENCIA GÓMEZ, MD PSYCHIATRY, PSYCHOSOMATIC MEDICINE. 1946 TYLER ST, SUITE 14 HOLLYWOOD, FL, 33020. (754) 210-5363

Authorization to release psychotherapy notes and medical records

1. Authorization. This shall serve as authorization for the medical practice specializing in psychiatry known as Integrated Mind Medicine to release the information identified in Section 2 below:

2. Information to be released. Medical information and psychotherapy notes. I understand that records You release contain information that is highly confidential and personal in nature. Psycho-therapy notes are recorded by a healthcare provider who is a mental health professional documenting or analyzing the contents of the conversation during a private counseling session or a group, joint, or family counseling session. Records may contain information recorded by a mental health professional during a counseling session and may contain information relating to AIDs/ARC, sexual preference, illegal drug use, alcohol abuse, personal history, medical history, family history, as well as medication records, lab results and information from other sources.

3. Purpose use of information requested. The information requested will be used for my own purposes or if not, then it will be used for the following:

4. Right to revoke authorization. I understand that I may revoke this Authorization at any time by notifying you in writing at the address set forth at the top of this page. Unless otherwise specified, this authorization expires on

5. Right to inspect information. I understand that I have the right to inspect the information to be disclosed.

6. Right to limit authorization. I understand that I may request that You release a short narrative statement, rather than by entire record.

Please include the following in the content of the short narrative statement:

Date treatment began and ended.
Treatment methodology and diagnosis
Medications prescribed
Confirmation that I showed no suicidal or homicidal ideations.

Initial one or more below
Signature   Please release only a short narrative statement as outlined in number six below.
Signature   Please release my entire medical file, including psychotherapy notes.
Signature   Please discuss my case with my therapist/physician, listed above, for coordination of care.
Signature   Please release a detailed narrative report based on information contained in my psychotherapy notes.

Other

Print Name

Date of Birth

Date

Signature

Today's Date

Date