Release of Information in Blue Bell, Pa

(Fill in patient’s name even if patient is a minor)

DOB

(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

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 Patient

Date

Signature of Parent or Guardian (if patient is less than 14 years old)

Date

AUTHORIZATION TO RECEIVE AND DISCLOSE MENTAL HEALTH AND MEDICAL INFORMATION

Information shared may include any of following: