Hipaa Authorization To Disclose Protected Health Information To Primary Care Physician

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Authorization to Disclose Protected Health Information to Primary Care Physician
Communication between behavioral health providers and your primary care physician (PCP) is important to ensure that you receive comprehensive and quality
health care. This form will allow your Behavioral Health Provider to share protected health information (PHI) with your Primary Care Physician (PCP). This
information will not be released without your signed authorization. This PHI may include diagnosis, treatment plan, progress, and medication if necessary.
I,
,
,
/
/
(Patient Name – Please Print)
(Patient Identification Number)
(Patient Date of Birth - MM/DD/YYYY)
authorize
, to release protected health information related to my evaluation and treatment to:
(Provider Name – Please Print)
PCP Name:
PCP Phone:
PCP Address:
(Street)
(City)
(State)
(Zip Code)
Information to be completed by Behavioral Health Provider
I saw
on
for
(Patient Name – Please Print)
(Date)
(Reason / Diagnosis)
Summary:
The following medication was or will be started (indicate medication & dosage):
If no medication is indicated, check as appropriate:
Medication not prescribed
Patient refused medication
Psychotherapy suggested before trying medication
Treatment recommendations:
Lab tests for the following:
CBC
Thyroid Studies
Chem Panel
EKG
Other treatment recommendations:
If you have any questions or would like to discuss this case in greater detail, please call me at:
(Phone Number)
(Provider Signature)
(Provider Printed Name)
(Licensure)
Patient Rights
You can end this authorization (permission to use or disclose information) any time by contacting:
v
If you make a request to end this authorization, it will not include information that has already been used or disclosed based on your previous
v
permission. For more information about this and other rights, please see the applicable Notice of Privacy Practices.
You cannot be required to sign this form as a condition of treatment, payment, enrollment, or eligibility for benefits.
v
Information that is disclosed as a result of this Authorization Form may be re-disclosed by the recipient and no longer protected by law.
v
You do not have to agree to this request to use or disclose your information.
v
Patient Authorization
I, the undersigned understand that I may revoke this consent at any time except to the extent that action has been taken in reliance upon it and that in any
event this consent shall expire six (6) months from the date of signature, unless another date is specified. I have read and understand the above information
and give my authorization:
PATIENT PLEASE CHECK ONE
To release any applicable mental health / substance abuse information to my primary care physician.
To release only medication information to my primary care physician.
I DO NOT give my authorization to release any information to my primary care physician.
(Patient Signature)
(Date)
(Signature of Patient’s Authorized Representative)
(Date)
If signed by Authorized Representative, describe relationship to patient:
PROVIDER: PLEASE SEND A COPY OF THIS SIGNED FORM TO THE PRIMARY CARE PHYSICIAN AND KEEP THE ORIGINAL IN
THE TREAMENT RECORD
NOTICE TO RECIPIENT OF INFORMATION
This information has been disclosed to you from records the confidentiality of which may be protected by federal and/or state law. If the records are protected under the federal regulations on
the confidentiality of alcohol and drug abuse patient records (42 CFR Part 2), you are prohibited from making any further disclosure of this information unless further disclosure is expressly
permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is
NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

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