Transcription of Authorization to Release Information - PsyCare
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Authorization to Release Information - PsyCare
PsyCare , professional medical corporationA comprehensive behavioral healthcare systemHEADQUARTERS: 4550 Kearny Villa Road, Suite 116, San Diego, CA 92123 Phone: (858) 279-1223 Release Fax: (858)467-7161 Authorization to Release InformationI hereby authorizeto Release All psychiatric/psychotherapy records(One Time OnlyOn-going up to one year)Initials Letter to:dated: Verbal Treatment Summary Other(One Time OnlyOn-goingup to one year__)Initial HereTo: Recipient's name, address & phone # s:Phone number:Fax number:Recipient s relationship to the Patient/Client:(If legal counsel, indicate: PsyCare Patient s attorney or Opposing Attorney) :(Patient/Client's Name)(Patient/Client's Date of Birth)Purpose of Release : (mandatory)This Authorization for use or disclosure of medicalinformationis being authorized by me givingPsyCare, Inc. permission to disclose mental health/psychiatric records and Information obtained inthe course of the diagnosis and/or treatment of my child or understand that the informationdisclosed pursuant to this Authorization might be re-disclosed by the recipient and may be no longerprotected by the Federal Privacy Regulation [45 CFR Part 164].
PsyCare, Inc. A professional medical corporation A comprehensive behavioral healthcare system HEADQUARTERS: 4550 Kearny Villa Road, Suite 116, San Diego, CA 92123
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