Hamilton Psychiatric Services

Purpose for Request

Release Proctected Health Information to Hamilton Psychiatric Services

Transferring to Another Practice

For personal use only (not transferring from practice)

Relocation out of area

Insurance Change Related. PLEASE INDICADE CARRIER

Discuss with

Employer Family Member Friend Others

Fill Name of Person / Facility Information Transfered to (required)

Name *

Practice Name

Phone Number

Fax Number

The following information is to be released: (Please check one)

Entire Medical Record. Records specifically protected under State and Federal Confidentiality Statues. I understand that the information to be disclosed may include diagnosis, prognosis, and treatment for physical and/or mental illness including treatment of substance abuse, AIDS/HIV related, genetic, venereal disease or tuberculosis information, which are protected under State and Federal law and prohibits any further disclosure without written consent of the persons to whom it pertains or otherwise provided by law

Only specific portions of the medical record. Itemize portions of record and time period of records to be released.

Date of Service

Comments

indicate specific records that may not be released

I understand that this authorization will remain in effect for 180 days or until I provide a written notice of revocation to Hamilton Psychiatric Services PrivacyOffice at the address listed above.The revocation will be effective immediately upon Hamilton PsychiatricServices receipt of the written notice.I understandthat revocation may not be made if the action has already been acted upon based on prior authorization

Information Release Form

Purpose for Request

Fill Name of Person / Facility Information Transfered to (required)

Office

Time Sheduled

Address

Email