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Authorization To Release Information
Authorization to release or obtain medical records.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Address
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
I authorize the Center for Therapy & Counseling Services, LLC, at 15 W Prospect St, Suite 2, East Brunswick, NJ 08816 to:
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Medical
Psychiatric
Drug & Alcohol Information
Obtain
Release
Medical
Psychiatric
Drug & Alcohol Information
Obtain
Release
Release to/Obtain information from: Name, address
Your answer
Release to/Obtain information from: title (school/DSS/parent/self/doctor/court, etc.)
*
Your answer
Release to/Obtain information from: phone number
*
Your answer
Release to/Obtain information from: fax number
*
Option 1
Type of program/treatment:
Inpatient Treatment
Outpatient Treatment
PHP/Day Treatment
Residential Treatment
Group Home
Other:
For the treatment period of (dates):
Your answer
Reason/purpose for release/disclosure:
*
Continuing care
Legal proceedings
Educational purposes
Placement
Parent/legal guardian request
Disability determination/SSI
Insurance
Other:
Required
Information to be release/obtained:
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History and physical
Psychosocial assessments
Psychiatric evaluations and notes
Progress notes (clinical)
Lab x-ray/ EKG
Treatment plans and updates
Consultations/referrals
Dates of treatment
Discharge summary (clinical)
Discharge summary (nursing)
Discharge summary (medical)
Medications/medication history
Other:
Required
Records will be sent by:
*
Fax
USPS
Hand-delivered
Held for pick-up
Email
Required
I understand that federal regulations 42 CFR part 2, Confidentiality of Alcohol and Drug Abuse Patient Records, protects and prohibits disclosure without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke authorization except to the extent that action has been taken and not retroactive to release of information already made in good faith. I understand that this authorization will automatically expire in 12 months from date signed.
*
I understand.
By entering my name below, I show that I understand and agree with the information filled out in this form. Client/Legal guardian name:
*
Your answer
Relationship to patient:
*
Your answer
Date of form completion:
*
MM
/
DD
/
YYYY
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