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
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.