RMNC Release of Medical Records

Release of Medical Records

Rocky Mountain Neuropsychology Consultants, LLC
190 East 9th Avenue, Suite 350, Denver, CO 80203

Phone: (720) 449-2499/Fax (720) 634-0719
Patient's Name:*

First NameMiddle NameLast Name
Patient's Date of Birth:*

MonthDayYear
Date
I hereby authorize Rocky Mountain Neuropsychology Consultants, LLC (RMNC) to obtain, release, and/or communicate the following protected information from my records (those checked):
Records to be released by RMNC:

Psychological or Neuropsychological Evaluation ResultsTreatment or Diagnostic RecordsSummary of TreatmentOther
Records release from RMNC to:
Name of Provider or Institution:
Address of Provider or Institution:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Provider or Institution:
Please enter a valid phone number.
Fax Number of Provider or Institution:
Please enter a valid fax number.
Records to be released to RMNC:

Psychological or Neuropsychological Evaluation ResultsPsychological or Neuropsychological Evaluation Raw DataPsychiatric/Psychological Treatment/Diagnostic RecordsMedical RecordsSummary of TreatmentAcademic/School RecordsIEP EvaluationsOccupational History RecordsLegal Documents/RecordsOther
Records release to RMNC from:
Name of Provider or Institution: *
Address of Provider or Institution:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Provider or Institution:*
Please enter a valid phone number.
Fax Number of Provider or Institution:
Please enter a valid fax number.
The purpose of this exchange of information is to:*

Conduct a formal evaluation and/or consultationClinical treatmentContinuation of care
The information exchanged should reflect material collected:*

In the last six monthsIn the last yearIn the last five yearsSince first contact with the patient
This authorization form is valid for:*

Three monthsSix monthsTwelve months
I may revoke my consent for the release of this information at any time except to the extent that the information was released prior to the revocation of consent.
Name of the patient or legal guardian:*

First NameLast Name
Signature*

Clear
Date of signature:*

MonthDayYear
Date
Should be Empty:

Release of Medical Records

190 East 9th Avenue, Suite 350, Denver, CO 80203

I hereby authorize Rocky Mountain Neuropsychology Consultants, LLC (RMNC) to obtain, release, and/or communicate the following protected information from my records (those checked):

Records release from RMNC to:

Records release to RMNC from: