PCP Coordination of Care Form

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Please provide the same email address that you use to communicate with the office.

Email *

Primary Care Physician Coordination of Care Form

The purpose of this document is for the therapist and your doctor to be able to communicate about your care.

Client Name *

Date of Birth *

YYYY

Primary Care Physician *

Phone Number *

Address *

Authorization *

I hereby authorize Melissa R. Tower, MA, LLP, my behavioral health provider, and my primary care physician to exchange information regarding my mental health/substance abuse treatment and medical healthcare; for coordination of care purposes as may be necessary for the administration and provision of my healthcare coverage. The information exchanged may include information on mental health care or substance abuse care and/or treatment (as protected under 42 CFR Part 2) such as diagnosis and treatment plan and medical information, including information regarding the presence or absence of HIV/AIDS. I understand that this authorization shall remain in effect for one year from the date of my signature below, or for the course of this treatment, whichever is longer. I understand that I may revoke this authorization at any time by written notice to my behavioral health provider. I also understand that it is my responsibility to notify this provider if I choose to change my primary care physician.

Required

Electronically signed by: *

You acknowledge that entering your name below constitutes as your legal signature and you are entering into a legal agreement.

Today's Date *

YYYY

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