AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

Please use the form below to submit yor authorization for release of health information (Note: Fields marked with * are required):

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Name of Patient-------------------------RELEASE OF INFORMATION FORM - Riverview Psychological Services, PC, 66 Middlebush Rd. – Wappingers Falls, NY 12590 *

Date of Birth: *

Name of parent or guardian (if patient is a minor):

I authorize release/exchange of information between Riverview Psychological Services and the following person or organization (name, address, phone): *

Patient/Guardian Name and Date (will count as electronic signature and consent to the Authorization below): *

Captcha (spam protection code) *

*

AUTHORIZATION: I give my permission for the information listed above to be exchanged between the above-named individuals or organizations. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it. This authorization will expire one year after the date signed. The above-named individuals or organizations should not redisclose my medical record to another party without further written consent. I will not hold above-named individuals or organizations nor Riverview Psychological Services, PC liable for any injury, whether mental or physical, resulting from any misunderstanding of information in the released report as a result of my not asking my Riverview Psychological Services practitioner for clarification of the information therein. In addition, I understand that the purpose of disclosure is for further mental health or medical care, legal investigation, insurance request, or other request for mental health information. The information exchanged may consist of copies of records (progress notes, test reports), verbal information, letter, proof of attendance, or other requested information.

Note: Fields marked with * are required

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

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