Consent for Release of Information

Consent for Release of Information Form – PDF Download

I, _____________________________________  (name) whose date of birth is _______________________, Address _____________________________________________________________________________ Do authorize Mary L. Wyant, MD PA to disclose and/ or obtain from: _________________________________________________________ (name of person or organization). Phone no: ________________________ Fax No: _________________________________

Initial each item to be disclosed:

___ Assessment                                                      ___ Diagnosis

___ Psychological Evaluation                             ___ Psychiatric Evaluation

___ Treatment Update                                          ___ Medication Management

___ Participation in Treatment                             ___ Educational Information

___ Drug Screens                                                  ___ Demographic Information

___ Discharge Summaries

___ Progress in Treatment                                     ___ All of the Above

The purpose of this disclosure is to improve assessment and treatment planning and coordinate treatment services.  If other purpose please specify: ______________________________________________________________.

I understand I have a right to revoke this authorization in writing at any time by sending written notification to Mary L Wyant MD PA at the above address.  I further understand that revocation of the authorization is not effective to the extent that action has already been taken in reliance on the authorization.

Unless sooner revoked, this consent expires on the following date: _________________________, or as otherwise indicated _____________________________________________________________________.  I understand that Mary L Wyant MD PA will not condition treatment on whether or not I consent to disclosure.  It has been explained to me that failure to authorize disclosure may have the following consequences: Limiting clarification of past medical history or treatment history.

Unless specifically requested in writing that the disclosure be made in a certain format, the right is reserved to disclose information as permitted by this authorization in any manner deemed appropriate and consistent with applicable law, including, but not limited to: verbally, electronically, or in a paper format.

Federal Law prohibits the person or organization to whom the disclosure is made from making further any further disclosure of substance abuse treatment information, unless it is expressly permitted by written authorization or as otherwise permitted by 421 C.F.R Part 2

I will be given a copy of the authorization for my records upon request.

Signature of Patient _____________________________________________ Date __________________

____________________________________________________________ Date __________________

Signature of Parent, Guardian or Personal Representative