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.