Patient Authorization Disclosure Or Receipt Of Psychotherapy Notes Form printable pdf download

PATIENT AUTHORIZATION

DISCLOSURE OR RECEIPT OF PSYCHOTHERAPY NOTES

Patient Name ____________________________________

Medical Record # _____________________________

Date of Birth

_____________________________________ Phone # (_______)____________________________

Patient Address__________________________________________________________________________________

___________________________________________________________________________________

Soc. Sec.#

____________________________________ (Providing your SS# is voluntary, but necessary to

accurately identify your medical records Failure to provide this information will likely delay the

processing of your request).

Approximate Dates of Treatment: ___________________________________________________________________

I authorize the following health care provider or facility to DISCLOSE or RECEIVE my patient information:

_____ University Hospital (Inpatient)

_____ University Neuropsychiatric Institute (UNI)

_____ Community Clinics

_____ Sugarhouse Clinic

_____ Madsen Clinics

_____ Moran Eye Center

_____ University Orthopǽdics Center

_____ Huntsman Cancer Hospital

_____ Huntsman Cancer Institute

_____ Outpatient Clinic(s):______________________________________________________ __________

_____ Specific Provider(s): ________________________________________________________________

_____ Other: Name/Credentials: __________________________________________________________

Phone:____________________________ Relationship: _________________________________________

Address: _______________________________________________________________________________

Please disclose my psychotherapy notes.

Please indicate the purpose of the disclosure of your psychotherapy notes:

____________________________________________________________________________.

If applicable, I understand that based on the dates, providers, and information I have designated above, the

disclosure UUHSC makes pursuant to this authorization may include information regarding my participation in a

substance abuse treatment program.

I understand that if the authorized recipient of this information is not a health care provider or health plan covered

by federal privacy regulations, the information he/she receives will no longer be protected by these regulations,

Note: This form is used only in very specific circumstances. Contact the HIPAA Privacy Office about its use.

1.4P Form - Authorization Psychotherapy Notes.doc

Rev: 08/12/2005

Patient Authorization Disclosure Or Receipt Of Psychotherapy Notes Form