Greenlake Psychiatric Release of Information

Authorization for Release of Patient Health Care Information

Patient Name

Date of birth

Date

I hearby authorize release of medical records and discussion of my care BETWEEN:

GREENLAKE PSYCHIATRIC CARE

AND

This information should go (choose one or both)

From Greenlake Psychiatric to the above partyTo Greenlake Psychiatric from the above party

Name of person or provider

email

example@example.com

Office/Organization

Telephone

Fax

I authorize the above parties to communicate via email about my medical and psychiatric care.

check if you agree

ALL information about my health may be released

check if you agree

Which information should NOT be released

Reason for release

Date or situation release ends

I understand that I may inspect or copy the protected health information to be disclosed, that I may revoke this authorization in writing by contacting either of the above offices, and that information disclosed pursuant to this authorization my be subject to re-disclosure by the recipient and may no longer be protected by HIPPA.

I understand I may refuse to sign this authorization and that you will not condition treatment, payment or enrollment. However, I do need to sign to take part in a research study, for research-related treatment and to receive health care when the purpose is to create health care information for a third party.

Signature

Clear

Date

Printed name if guardian

Relationship

Confidential Heath Information Fax

This message is intended only for the person listed above. If the reader of this fax is not the intended recipient or this transmission is received in error, please notify us and shred this information. Thank you for your assistance.