Authorization For Release Of Psychotherapy Notes Form printable pdf download

Patient Information: I give permission to release the Psychotherapy Notes of:

(One patient per form)

Patient Name: ____________________________________________

Date of Birth: __________________________________

Street Address: ___________________________________________

MR# or last 4 numbers of ________________________

City, State, Zip: ___________________________________________

Telephone: (

) ______________________________

Email address: _________________________________________________________________________________________________________

Release Information From:

Release Information To:

__________________________________________________________

_________________________________________________________

(List applicable Facility(s) and/or Practice(s)

(Name of facility, person, company)

(Relationship)

__________________________________________________________

_________________________________________________________

(City, State, Zip Code)

__________________________________________________________

(Phone number)

_________________________________________________________

(Phone number)

(Fax number)

PURPOSE OF RELEASE (check reason):

Request of individual/personal

Continued patient care

Insurance

Legal purpose including discussions & proceedings

Other_____________________________________________________

Fill in the dates of therapy sessions for Psychotherapy Notes to be released:

Dates of therapy sessions:

From: ________________________________________ To _________________________________________

FORMAT: (Check all that may apply)

DELIVERY METHOD:

CD (charges may apply)

Reg.US Mail

Pick-up

Fax, where permitted

Paper copy (charges may apply)

Overnight/Express Mail Service, where permitted

Other_____________________

Secure email, where permitted

Other: ________________________________________________

PATIENT’S RIGHTS – I understand that:



I can cancel this permission at any time. I must cancel in writing and send or deliver cancellation to releasing facility

or practice named above. Any cancellation will apply only to information not yet released by the facility or practice.



This is a full release which may include information related to behavioral/mental health, drug and alcohol abuse

treatment (in compliance with 42 CFR Part 2), genetics, HIV/AIDS, and other sexually transmitted diseases.



Once my health information is released, the recipient may disclose or share my information with others and my

information may no longer be protected by federal and state privacy protections.



Refusing to sign this form will not prevent my ability to get treatment, payment, enrollment in health plan, or

eligibility for benefits.



CHS will not share or use my health information without my permission other than by ways listed in CHS’s Notice of

Privacy Practices or as required by law. The Notice of Privacy Practices is available at



A fee may be charged for providing the protected health information.



I have a right to receive a copy of this form upon request.

This permission expires one year after the date of my signature unless an earlier date or event is written here: ____________

Signature: _________________________________Print Name: ___________________________________Date:______________

Note: if the patient lacks legal capacity or is unable to sign, an authorized personal representative may sign this form.

Note the relationship/authority if signature is not that of the patient: (Written Proof May be Requested)

Healthcare Agent/POA

Guardian

Executor/Administrator/Attorney in Fact

Spouse

Parent

Adult Child

Affidavit Next of Kin

Other: ______________________________

Note: If minor consented for their outpatient treatment for pregnancy, sexually transmitted disease or behavioral/mental

health without parental consent, the minor must sign this authorization. When the patient is a minor being treated for

substance abuse, the minor must sign this authorization, regardless of who consented for treatment.

Signature of Minor:____________________________________Print Name: _________________________________Date: __________________

Authorization given to patient / Date of release:

via

Mail

Fax

Other

ID Verified

DL/Other ID_______

CHS Employee Name & Title:

CHS Employee Signature:

Date_______________

Patient Information or Sticker

*905*

Name:

Carolinas HealthCare System

DOB:

AUTHORIZATION FOR RELEASE

Medical Record #:

OF PSYCHOTHERAPY NOTES

Authorization For Release Of Psychotherapy Notes Form

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