Plymouth Psych Group Release of Information

AUTHORIZATION FOR RELEASE AND EXCHANGE OF CONFIDENTIAL INFORMATION

for Plymouth Psych Group
Patient Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Date Date Picker Icon

Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Telephone: *

Area Code Phone Number
I authorize Plymouth Psych Group to (choose one): *

RECEIVE information FROM the clinic/provider listed below RELEASE information TO the clinic/provider listed below
Name of Clinic/Provider *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone *

Area Code Phone Number
Fax *

Area Code Phone Number
THE FOLLOWING INFORMATION:
Most Recent Evaluation + Last 3 progress notes

Yes
Date From:

Month Day Year
Date Picker Icon
Date To:

Month Day Year
Date Picker Icon
Please check all that apply

Medical Records School Records Progress Notes Evaluations Labs/Radiology Medication History Psychological Testing Letter/Documentation Contact by Telephone Leave Message
I am requesting this information be released for the following purpose:

Continued Care Insurance Legal Personal
Information will be faxed unless otherwise indicated here:
With the exception of psychotherapy notes, all records pertaining to psychiatric mental health, chemical dependency and/or AIDS/HIV related illness/testing will be released unless otherwise indicated by a check mark here: *
Please indicate any restrictions. (Specify) *
I understand I may revoke this authorization by written request at any time to the address listed at the top of this form.

I understand that the revocation will not apply to the information that has already been released in response to this authorization.
This authorization will automatically expire one year from the date of my signature, or a lesser period of time if specified here. The expiration period noted here may exceed one year only in certain situations as specified by law. *
understand that once the information is released pursuant to this authorization, Plymouth Psych Group cannot prevent the re-disclosure of the information to another third party.

I understand this authorization must be filled out completely and signed in order to be considered valid.

A copy of this authorization is as valid as the original bearing my signature.
I understand there may be a charge associated with the Release of Information Services rendered. There is no charge for release of information to other health care facilities.
Name/Signature of Legal Representative *

Clear
Name/Signature of Client if 16 or older

Clear
Date *

Month Day Year
Date Picker Icon
Enter the message as it's shown *
Should be Empty:

AUTHORIZATION FOR RELEASE AND EXCHANGE OF CONFIDENTIAL INFORMATION

THE FOLLOWING INFORMATION: