Release of Information AUTHORIZATION TO RECEIVE AND DISCLOSE MENTAL HEALTH AND MEDICAL INFORMATION I (Fill in patient’s name even if patient is a minor) DOB MM slash DD slash YYYY (Fill in patient’s date of birth)Hereby authorize Blue Bell Psychiatry and its providers to receive and disclose medical, mental health and addiction treatment records with (Fill in outside provider’s name and contact information. Outside provider may include therapist, school or any other applicable entity/individual) Information shared may include any of following:CHECK INFORMATION TO BE SENT medical and/or psychiatric evaluation medical and/or psychiatric progress notes psychological testing laboratory studies electrocardiogram x-ray reports others CHECK INFORMATION TO BE SHARED medical and/or psychiatric evaluation medical and/or psychiatric progress notes psychological testing laboratory studies electrocardiogram x-ray reports others Others Others Information will be used both now and in the future for the purpose of coordination/ determination of care and treatment planning. This information should be received from and/or disclosed to: Providers and Staff of Blue Bell Psychiatry. This consent also acknowledges my permission for the above-mentioned parties to have periodic exchanges of information (including verbal communication) at their discretion. I understand that I have a right to meet with my clinician to inspect my medical, mental health and addiction treatment record. This authorization releases Blue Bell Psychiatry and its providers from any and all legal liability that may arise as a result of their compliance with my request. This consent is subject to revocation at any time except that action has been taken in reliance thereon. My signature below attests to the fact that I have read this form, understand its content and request that the above information be released as specified. Signature of PatientDate MM slash DD slash YYYY Signature of Parent or Guardian (if patient is less than 14 years old)Date MM slash DD slash YYYY
