vortexpsychiatry.com - Consent for Release of Medical Records

Consent for Request/Release of Medical Records
Patient Name:

First NameLast Name
DOB:

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Date
Phone:
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Address

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I, Patient's Name hereby authorize Your Doctor’s Name , Your Doctor’s Fax Number , Your Doctor’s Mailing Address , Your Doctor’s Phone to provide my medical records, discuss my case/treatment, and release pertinent information to [ Type a label ] and Vortex Psychiatry staff for the purpose of initiating/continuing treatment. I understand that areas of my medical record including information pertaining to mental health, drug and/or alcohol abuse will be included unless I specify that the following areas are not to be released: Type a label
Please fax or email the following information to Vortex Psychiatry:

Medical Problem ListMedication ListLast 5 clinic visit notesMost recent EKG and lab testsOther
I understand that I have a right to receive a copy of this request. I further understand that I may revoke this consent in writing at any time except to the extent that action has been taken.
Patient’s Signature

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Date

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Consent for Request/Release of Medical Records