FORM-Release of Information

This notice describes how medical and drug and alcohol related information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Phone number: 704-237-4240
Fax number: 704-547-3150
Email: info@cehcharlotte.com

Acknowledgement(Required)

Release of Information forms do not permit a person to make decisions for a patient. If someone other than the legal guardian is going to bring the patient to an appointment, the parents can fill out a Release of Information form but will also need to consent to the attending party making decisions in place of the parent.

It is in the best interest of both the patient and parents for the parent to attend at least the first appointment so that they may provide approval moving forward.

I understand and agree.

Patient Information:(Required)

I give permission to release the health information of:

First Last

Patient Date of Birth(Required)

Patient Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Email(Required)

I hereby authorize The Center for Emotional Health to(Required)

Release medical records TO:

Obtain medical records FROM:

Name of Facility or Name of Person(Required)

Name of Doctor or Relation to Patient (if parent/guardian)(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Fax Number(Required)

Please check one or more(Required)

Verbal Communication (Phone)

Written Communication (Email)

Actual Records Released (Medical Records)

If actual records, dates to be released are from:

To:

Authorization valid until:(Required)

If no date is provided, this authorization will expire one year after the date of the signature below.

Please select the type of information you would like released:(Required)

Please select all that apply.

Office Visits / Progress Notes

Clinical Comprehensive Assessment

Entire Patient Record

Laboratory Reports

Medications

Disability Paperwork

Purpose of release:(Required)

Please select one.

Continued patient care

Disability

Insurance

Legal purpose

Other

Patient Rights(Required)

I understand that I have a right to revoke this authorization at any time by notifying the Medical Record Department of the above named organization in writing. I understand that revocation will not apply to information that has already been released in response to this authorization. I understand that my treatment cannot be conditioned on signing this authorization unless I am being treated so that a third party can receive my health information, such as employer for a return to work evaluation or insurance company for eligibility.

I acknowledge and hereby consent that the released information may contain alcohol, drug abuse, psychiatric diagnosis, and testing results.

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person listed above.

Electronic Signature of Patient (or Parent/Legal Guardian)(Required)

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

First Last

Date(Required)

Center for Emotional Health Release of Information

Patients

Company

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