Release of Information Form

Authorization for Release of Information

The PsyClinic/ Mohamed S. Ahmed, MD, PA
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Birth Date

MonthDayYear
Email
example@example.com
Last 4 SSN
I hereby AUTHORIZE The Psyclinic/ Mohamed S. Ahmed MD, PA

To Obtain FromTo Release To
Release Information to the Following
Name

First NameLast Name
Organization
Phone Number
Fax Number
Email Address
Delivery Method
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Disclosure

Treatment/Continue CareImmigrationPersonal UseLegal PurposeBilling, Insurance ClaimDisability DeterminationSchoolEmploymentOtherOther
Information to be Disclosed

Current year 2024 or laterLast Office Note OnlyTherapy NotesVisit Summary Only/Med ListAll Office VisitsRadiology ReportsSleep StudiesEKG/Cardiology ReportsLab ResultsADHD Testing reports or Psychological ReportsVerbal CommunicationClearance LetterSchool/Work ExcuseLetters/ FormsSchool Admin MedicationFMLA/STD FormsDisability FormsOtherOther
Please select your choice*

Mental Health Records ( Excluding Psychotherapy Notes)Genetic Information( Genetic Testing)Drug, Alcohol or Substance Abuse Records
This authorization is valid until the earlier of the death of the individual: the individual reaching the age of Majority; or permission is withdrawn or the following Expiration Date:

MonthDayYear
Date
Consent

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time with a written notice stating my intent to revoke this authorization to the person or organization mentioned above. I have read this form and agree to the use and disclosure of information as described.
Printed Name of Legally Authorized Representative
First Name Last Name
Relationship Self Parent of Minor Guardian Other
Signature of individual's legally Authorized Representative

Clear
Should be Empty:

Authorization for Release of Information

Release Information to the Following