Authorization to Release Information - PsyCare

1 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.

2 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].This disclosure ofmedical/psychiatric Information complies with the terms of the Confidentiality of MedicalInformation Act of 1981, section 56, et. Seq, California Civil AUTHORIZE:To Release or disclose any Information or records relating to the diagnosis,treatment or other therapyfor the conditions of drug abuse, alcoholism or alcohol abuse, infectionwith the human immunodeficiency virus (HIV), sickle cell anemia, psychotherapy, educational,psychological, and laboratory test results,andgenetic/familial Information .

3 IF MY CONSENT TOTHIS Information IS LIMITED, THE LIMITATION IS WRITTEN HERE:I may revoke this Authorization at any time, in writing to the Administration department, except tothe extent action has been taken in reliance upon this it isnot earlier revoked, this consentshall terminate without express revocation one year from date shown : _____(Date)(Patient/Client's Signature)(If signed by other than Patient/Client, please indicate relationship)_____(Signature of Minor-ages 12-17; If unable/unwilling to sign list reason)OFFICE USE ONLY(Must be completed before submittingrequest to Admin): MD S ONLY-Consent to Release : _____ Therapist s initials (Pt seen individually):_____ Fee collected?

4 (Initials/ type of payment):_____ SEND FROM OFFICE SENT FROM #Office:Staff Initials:ADMINISTRATION BOX: Ok to Release Forms/ Letter / Paperwork(circle one) OK to Release Records OK communicate Verbally only_____ _____Administrative Signature Dat