Authorization to obtain and release confidential information for the purpose of assessment and future treatment.

Please provide the contact information for your current and/or past nutritionist, therapist, physician, specialist, psychiatrist, treatment center, coach,school/university personnel and any family members with whom you choose to have Anne Till Consulting LLC communicate as part of your treatment team. If you do not want us to share information or have access to information, please indicate this in the next question in this form.

First Name Middle Name Last Name

Would you like us to be able to obtain medical records, or share information about your care with a family member, or another medical provider?

Are you (the patient) older than 18 years of age?

Today's Date

Date

Patient Name

First Name Middle Name Last Name

Name of Legal Guardian (if under 18 years of age)

First Name Middle Name Last Name

I {nameOf5} hereby authorize Anne Till Consulting LLC to obtain and release information regarding past and current treatment for {patientName} to and from the following people and/or organizations listed below. This information may include full health history, general and specific information regarding: nutritional, lifestyle, medical and/or psychological or social assessment/evaluation/counseling/treatment and progress notes, laboratory tests, growth charts, special evaluations/testing, diet prescriptions and provided dietary and lifestyle guidelines, school performance, social and emotional functioning, special learning problems or capabilities, educational testing, etc.

{todaysDate}

I {patientName} hereby authorize Anne Till Consulting LLC to obtain and release information regarding past and current treatment for myself {patientName} to and from the following people and/or organizations listed below. This information may include full health history, general and specific information regarding: nutritional, lifestyle, medical and/or psychological or social assessment/evaluation/counseling/treatment and progress notes, laboratory tests, growth charts, special evaluations/testing, diet prescriptions and provided dietary and lifestyle guidelines, school performance, social and emotional functioning, special learning problems or capabilities, educational testing, etc.

{todaysDate}

Please select how many people or organizations should be added to this form. For example you might add your Primary Care doctor, your spouse and a specialist such as an endocrinologist. You would therefore select 3 people/organizations from the drop down box. This form allows for a maximum of 6 slots. If you have more than 6 people that need to be added please inform our front desk staff and they will provide a paper copy for you to complete.

1. Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment

Name of Person / Doctor / Provider

First Name Last Name

Relationship /Organization/ Practice Name

Address (if known)

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number

Area Code Phone Number

Email (if known)

example@example.com

Fax Number (if available)

Area Code Phone Number

2. Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment

Name of Person / Doctor / Provider

First Name Last Name

Relationship / Organization/ Practice Name

Address (if known)

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number

Area Code Phone Number

Email (if known)

example@example.com

Fax Number (if available)

Area Code Phone Number

3. Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment

Name of Person / Doctor / Provider

First Name Last Name

Relationship /Organization/ Practice Name

Address (if known)

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number

Area Code Phone Number

Email (if known)

example@example.com

Fax Number (if available)

Area Code Phone Number

4. Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment

Name of Person / Doctor / Provider

First Name Last Name

Relationship /Organization/ Practice Name

Address (if known)

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number

Area Code Phone Number

Email (if known)

example@example.com

Fax Number (if available)

Area Code Phone Number

5. Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment

Relationship /Name of Person / Doctor / Provider

First Name Last Name

Organization/ Practice Name

Address (if known)

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number

Area Code Phone Number

Email (if known)

example@example.com

Fax Number (if available)

Area Code Phone Number

6. Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment

Name of Person / Doctor / Provider

First Name Last Name

Relationship /Organization/ Practice Name

Address (if known)

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number

Area Code Phone Number

Email (if known)

example@example.com

Fax Number (if available)

Area Code Phone Number

Signature for Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment. I understand that my records are confidential and will not be disclosed without my consent unless under legal compulsion or in life threatening situations. I also understand that I may revoke consent at any time, providing that the revocation is executed in writing to Anne Till Consulting LLC at 105B Kilmayne Drive , Cary NC 27511.Revocation will not affect any disclosures acting upon by this disclosure and prior to the request for revocation. Information disclosed pursuant to this authorization may be re-disclosed and is no longer protected by federal and state privacy rules. Authorization of disclosure of the above stated information is voluntary and this authorization is not intended to alter the patient’s ability to receive medical care from any health care provider. Unless stated, this authorization remains in effect for two years after last consultation with a provider at Anne Till Consulting LLC

Clear