Authorization to Release Health Information
I HEARBY AUTHORIZE Foundation Psychiatry, P.C. to release the following medical and clinical information:
For the purpose of:
With the following:
The above-mentioned Protected Health Information may be subject to re-disclosure by the party receiving the information and may no longer be protected by the privacy rules. I understand that this authorization to exchange information becomes effective when I sign this release and that I may revoke this authorization at anytime by written notice to Foundation Psychiatry, P.C. However, such a revocation shall not affect any disclosures already made in reliance on your prior authorization. My refusal to sign this form will not affect my ability to receive care at Foundation Psychiatry, P.C. This authorization expires in 12 months and any further disclosure after that time will require signing a new form.
Signature of Parent/Legal Guardian if applicable:
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