authorization to disclose health information

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AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

I hereby authorize Certus Psychiatry & Integrated Care to release medical information from the records of:

Patient Name*

Name

Last 4 digits of SS#*

DOB*

I understand that the information released pursuant to this request will include health information related to psychiatric treatment, psychotherapy, HIV or AIDS-related conditions, communicable diseases, and treatment for drug and alcohol abuse, if any are applicable This authorization is for the release of all health information unless limited as follows:

I understand that my information is protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as amended. Regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records may also apply. I understand that unless revoked, this authorization is valid for the period of time needed to fulfill its purpose and up to three years, except for disclosures for financial transactions, wherein the authorization is valid indefinitely.

This information is to be disclosed to:

Company Name is Applicable

Name of Person*

Phone*

Address*

Street Address City State ZIP Code

By signing below, I represent that I have read, understood, and consent to this disclosure.

Patient Name*

Patient Email*

Date*

Witness Name*

Name

This field is for validation purposes and should be left unchanged.

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Winston-Salem Office

1255 Creekshire Way
(between Brixx and Firebirds)

Two Convenient
Locations!

833.701.3111

Raleigh Office

1350 Sunday Drive
Suite 101

authorization to disclose health information