Adolescent Child and Adult Psychiatry

Raleigh Location: 4041 Ed Drive #108, Raleigh NC 27612

Clayton Location: 501 Gateway Drive, Suite 101, Clayton NC 27520
Phone: (919) 783-8377 Fax (919) 324-3404

RELEASE OF INFORMATION

Patient ______DOB ______

Address ______City ______State ______Zip Code ______

Information Released From:Information Released To:

______

Name (Health Care Provider)Name (Hospital, Agency, MD)

______

Address Address

______

City, State, Zip Code City, State, Zip Code

______

Telephone Number Fax Number Telephone Number Fax Number

Reciprocal Authorization for Release Information (Check if applicable)

_____ A reciprocal authorization allows Adolescent Child & Adult Psychiatry to have continuous dialogue between the medical personnel of Adolescent Child & Adult Psychiatry and the individual or group identified above.

Description of Information to be Released:

_____Complete Medical Record _____Psychiatric Records _____Psychological Records _____ Records of Psychiatric Hospitalizations _____Diagnostic & Lab Testing _____ Other (______)

Regarding services rendered during the following dates ______

Purpose of Release of Records (check one)

_____Continuing Treatment ______Personal ______Legal Involvement ______Disability Determination ______Moving ______Insurance ______Other

I understand that this consent is only valid for one (1) year from ______(today’s date) unless signed for:

Establishment of financial benefits in which case the consent will be valid until the end of the benefit period
Release of information to the Department of Motor Vehicles, the Court and the Department of Corrections for information needed to reinstate driving privileges. The consent will then remain valid until the reinstatement of driving privileges.

Confidential information relative to a patient with HIV infection, AIDS or AIDS related conditions shall only be released in accordance with G.S. 130A-143. If the records or information being released involve alcohol or drug abuse, my records are protected by federal law and regulations relating to “confidentiality of alcohol or drug abuse patient records.” (42 CFR.Part 2).Whenever authorization is required for the release of this information, the consent shall specify that the information to be released includes information relative to alcohol or drug abuse, HIV infection, AIDS or AIDS related conditions. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

I have read this authorization and understand what information will be used or disclosed, who may use and disclose the information, and the recipients(s) of that information. I specifically authorize any medical personnel of Adolescent Child & Adult Psychiatry, or any other individual listed above to disclose my protected health information as described on this form to the recipients listed. 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 health information. I further understand that I retain the right to revoke this authorization in writing, except to the extent that action has been taken in reliance on this authorization or, if applicable, during a contestability period. This authorization shall be valid for one year from signature. I hereby release Adolescent Child & Adult Psychiatry from all legal responsibility or liability that may arise from this authorization.

Patient or Legal Guardian Signature______Date ______

Witness ______Date ______