Consent for Release of Medical Information
To be completed by patient/parent/guardian
Authorization for Use Disclosure of Protected Health Information.
Patient Information
Patient Full Name:
*
First Name
Last Name
Patient Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Patient Date of Birth:
*
-
Month
-
Day
Year
Date
Home Phone:
*
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Where would you like your medical information sent?
Release Information To:
*
I hereby authorize release of my medical information to this entity.
Release Information From:
*
I hereby authorize release of my medical information from this entity.
Electronic Delivery To:
Name/Facility
Attention To:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Fax Number:
*
Please enter a valid phone number.
Some Details Regarding Your Request
Purpose of Request:
*
Personal
Insurance
Legal
Other
Information to be Released:
*
Complete Clinical Documentation
Other
Authorization to Release Protected Information
*Required-Please indicating how protected information should be handled.
I want my entire record released
*
Yes
No
Other
I understand that if I check that I want my Entire Record released, all records created in the course of my treatment on the dates listed above, including information regarding my medical condition, mental health, alcohol/drug abuse diagnosis and treatment, genetic testing information, and communicable disease status, including AIDS/HIV, will be released.
*
Yes
No
Other
If you DO NOT want your Entire Records released, please check what you would like excluded:
Mental Health Treatment
HIV Tests and Related Information
Genetic Testing Information
Hepatitis C Tests and Related Information
Alcohol and/of Substance
Consent
I specifically authorize Psychiatry of Austin or AutoPsych to disclose my Protected Health Information as described on this form to the recipients listed above. I understand that when the information is used or disclosed pursuant to this authorization, it may be subject to re disclosure by the recipient and may no longer be protected by state or federal privacy regulations. I further understand that I retain the right to revoke this authorization, if done according to the steps set forth above. I understand Psychiatry of Austin or AutoPsych is authorized by me to use or disclose my Protected Health Information for a purpose (described in this document) other than treatment, payment, or healthcare operations. I have read the authorization and understand what information will be used or disclosed, who may use and disclose this information, and the recipient(s) of that information. I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned upon my signing this authorization. Psychiatry of Austin or AutoPsych reserves the right to disclose information electronically for treatment, payment, or healthcare operations, unless otherwise required by law.
Signature
*
Submit payment here:
*
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Medical Records Request
Formal request for Psychiatric Medical Records. Service includes record completion, review, packaging and electronic delivery. Service may be denied by provider if clinically indicated upon professional review of requested documentation.
$
25.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Submit
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