IW RELEASE OF INFORMATION

Insight Wellness

Develop insight. Find wellness.
AUTHORIZATION & CONSENT FOR RELEASE OF INFORMATION
Please read entire document and fill in required sections in order to release information to the provider of your choice. When all fields are completed press SUBMIT.
This will document authorizes your provider(s) to release and receive written and/or verbal information regarding your treatment while with Insight Wellness. By signing this document you understand that your therapists and/or representatives of Insight Wellness will communicate with listed provider(s) on your behalf.

(If you have more than one provider please complete a form for each - including your PCP or Pediatrician)

By signing you understand that your expressed consent is required to release any health care information relating to testing, diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health or drug/alcohol treatment or use.

You have a right to inspect and to receive a copy of the information to be disclosed and you may revoke this authorization at any time in writing, except to the extent that action has to be taken based on this authorization. You understand that you may specify a date for the expiration of this authorization, but that it shall expire by Law, without my express revocation, one year from the date written below, unless the Client is a resident of a nursing home.

Any released information may be beyond the reach of protection of federal law (HIPAA).
Full Name (Client name - do not use nicknames please)*
Provider Name (Please include license type (ie. Dr. Jane Doe or Jane Doe, NP) If the name of the provider is unknown, please write the name of the organization.*
DOB:*
To/From (Enter Therapists Name or Insight Wellness)*
From: (Date you started services with provider or year)*
To: (Please type Present)*
This authorization includes release of the following information: (Please check all that may apply - Typically we check off All evaluations, Verbal Discussion of Case, Coordination of Care, And Records based on type of Provider)*

Emergency Room/Urgent Care RecordsMental Health RecordsHealth RecordsLab ReportsAll evaluationsDischarge SummaryMedication HistoryConsultation Notes/ReportsPhysicalPsychological Test ReportPsychosocial HistoryEducational RecordsPsychotherapy NotesDrug/Alcohol Treatment RecordsVerbal Discussion of CaseSurgical ReportsDiagnostic & PrescriptiveProvide services on school grounds as neededCoordination of Care (CHECK OFF IF BILLING/FINANCIAL & COMPLETE OTHER BELOW)
Additional request: Please provide any additional release requests here.

Other
I direct that this authorization expires on*
(Typically this expires after one year from date of signing)
Date*

MonthDayYear
Date
Signature of Client*

Clear
Signature of Parent or Authorized Representative (If needed)

Clear
Typed Parent/Guardian Name (If needed)
Relationship to Client*
(Please type SELF or identify the relationship you have with the client)
Press Submit when you have completed document.
Should be Empty:

AUTHORIZATION & CONSENT FOR RELEASE OF INFORMATION

Please read entire document and fill in required sections in order to release information to the provider of your choice. When all fields are completed press SUBMIT.

Press Submit when you have completed document.