Release of Information Form

Patient Name*

Date of Birth*

I authorize my clinician (named below) and/or his/her administrative staff to release and/or obtain by means of verbal, written, photocopy, or fax, certain confidential information about my psychiatric and/or medical treatment. This information may contain information regarding testing/treatment for HIV, AIDS virus and/or substance abuse under the provisions of P.A. 258 of 1974 as amended, Section 748 Subsection 5.

PAGR Clinician Name*

The clinician or his or her staff is authorized to release or obtain the following:*

Select All
Treatment Summary
Psychiatric/Psychological Evaluation
Physical Exam
Psychological Testing
Psychotherapy Notes
Laboratory Studies
Emails or Phone Notes

Other

Exclude the following:

This information should be released to/obtained from: (name, address, phone/fax)*

Purpose of Disclosure:

Continuation of care/discharge planning
Coordination of Treatment Services
Legal Purposes
Termination of Treatment
Personal Use

Other purpose of disclosure

I am also aware of all consequences that might occur as a result of signing this consent form or of my refusal to do so. My electronic signature means that I have read this form and/or have had it read to me and explained in a language I can understand.

As stated in our Notice of Privacy Practices, you have the right to revoke or terminate this authorization by submitting a written request to our Privacy Manager. This can be done in person or by mailing a request to Psychology Associates of Grand Rapids, 1000 Parchment Dr. SE, Grand Rapids, MI 49546.

This authorization will expire at the end of the calendar year in which the authorization was initiated, unless you specify an earlier termination. You must submit a new authorization date to continue the authorization. You have the right to terminate this authorization at any time. You must notify our Privacy Manager, in writing if you decide to terminate the authorization prior to the normal expiration date.

Date to expire (if prior to one year from signature date):

We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization will no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of Psychology Associates of Grand Rapids.

If the patient does not consent to this release, his/her treatment will not be compromised in any way.

A true and exact photostatic/faxed copy of this authorization shall have the same effect as the original.

Authorization Electronic Signature*

I agree to the authorization to release or obtain the information listed above
I do not agree

Date of Electronic Signature*

Name of Witness