Ross Center Consent For Release Of Patient Information
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1CONSENT FOR RELEASE OF PATIENT INFORMATION
Patient Name:
______________________________________________________________
Date of Birth: ___________________________
PatientAddress:
________________________________________________________________________________________________________
I hereby consent to the release of my protected health information (please fill in the appropriate section):
From:
To:
Name_________________________________________________________________
Manhattan Psychiatric Associates
th
th
57 W. 57
St (@6
Ave.)
Address_______________________________________________________________
Suite 912
______________________________________________________________________
New York, NY 10019
______________________________________________________________________
Phone: 855-767-7287
Fax: 646-687-7893
Phone_________________________________________________________________
Fax___________________________________________________________________
From:
To:
Name______________________________________________________________
Manhattan Psychiatric Associates
Address____________________________________________________________
th
th
57 W. 57
Street (@6
Ave.)
Suite 912
___________________________________________________________________
New York, NY 10019
___________________________________________________________________
Phone: 855-767-7287
Phone______________________________________________________________
Fax: 646-687-7893
Fax________________________________________________________________
Psychiatry records
Psychotherapy notes
Substance Abuse records
Psychological testing records
Data shall include:
Other, please specify ____________________________________________
Continued/Coordinated care
Other, please specify
Specific purpose:
________________________________________
I understand that if the aforementioned records pertain to drug or alcohol abuse treatment, HIV/AIDS testing, treatment, or related illness that such information will
be released pursuant to this authorization form. I understand and agree that 1) I have a right to inspect my Protected Health Information; 2) I may revoke
this authorization in writing at any time; 3) this authorization will expire three hundred sixty five (365) days from the date written below; 4) District of Columbia Law
prohibits re-disclosure of Protected Mental Health Information (PHI) by the recipient without my consent; 5) the Ross Center may disclose my PHI without my consent
only in specific circumstances authorized by law; and 6) my treatment provider may refuse to disclose or allow my inspection of part or all of my PHI if he/she believes
that it is necessary to protect me or someone else from psychological or other harm.
This consent form has been explained to me and I understand the contents to be released, the need for the information, and that there are statutes and regulations
protecting the confidentiality of authorized information. I hereby acknowledge that this consent is truly voluntary and is valid until such request is fulfilled. Any
revocation of this consent will not apply to information that has previously been released in accordance with this consent.
___________________________________
__________________________________
Signature (Patient or Legal Guardian)
Witness
___________________________________
__________________________________
Date
Date
The Ross Center for Anxiety & Related Disorders, LLC
10
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