Medical Release Form

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By filling out the form below, the named person voluntarily gives consent to an authorize my health care provider RVA Psychiatry and Wellness, specifically Robert "Trip" Young, NP to use or disclose my health information during the term of this Authorization to the recipient(s) that I have identified below.

RVA Psychiatry and Wellness, LLC
3800 Stillman Parkway Ste 201
Henrico VA 23233
(P) 804-203-2855 (F) 804-509-0538

Email *

Patients Full Legal Name *

Date of Birth *

YYYY

Patient's Full Address *

Patient's Phone Number *

Name of Therapist, Health Care Entity, Family Member, and/or Other Party to release information - *

Full Address of Above Named *

Phone Number *

Fax Number *

If Under 18yrs Old Please List Parents Full Name Below

Information To Be Release *

All of my health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received by me

Specific Information Only (Please Indicate Below)

Required

Information To Be Release (If Specific Only)

Duration Of Release *

Ongoing From Date Signed Until 30 Days After Termination of Patient / Provider Relationship

Specific Period of Time (Specify Time Period Below)

Required

Duration Of Release (If Specific Dates Only)

Writing your full name below signifies that you understand this form authorizes RVA Psychiatry and Wellness, LLC to release and/or exchange medical information with the above named Health Care Entity / Individual. If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation to the RVA Psychiatry and Wellness, LLC. The revocation will be effective immediately upon my health care provider’s receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation. *

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