Coordination of Care between Health Care Providers and Release of Information

Communication between your therapist and your medical doctor is important to ensure that you receive comprehensive and quality health care. This form will allow HPC to share health information with your other doctors. This information will not be released without your signed authorization.

Patient Rights

You may end this authorization (permission to use or disclose information) any time by contacting the practitioner’s office.
You have a right to a copy of this signed authorization.
If you choose not to agree with this request, your benefits or services will not be affected.

Patient Authorization

I hereby authorize the release of records regarding any medical, mental health and/or alcohol/drug abuse diagnosis or treatment. I understand that these records are protected by Federal and state laws and cannot be disclosed without my consent unless otherwise provided in the regulations. I also understand that I may revoke this consent at any time and must do so in writing.

Patient Name

I authorize Hollywood Psychology Center to release protected health information related to my treatment with my health care providers as follows:

Primary Care Doctor

Name

Phone

Psychiatrist

Name

Phone

Any restrictions

Patient’s Initials, as Signature