Synergiquehealing.com - ROR Authorization Form, Synergique Healing 2022

Authorization To Disclose Or Release of Record
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Apt#/Unit
Entity
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Purpose: I authorize the release of my health information for the following specific purpose
Information to be disclosed: I authorize the release of the following health information (check the applicable box below)

Other
Date Start

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date End

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I grant special authorization for the following information (Please Initial) to be shared:

Initial Psychotherapy Notes

Initial Alcohol/Drug Abuse

I acknowledge and understand this authorization will waive my rights to confidentiality regarding the information released per this consent. I hereby release Synergique Healing, PA, and its staff from all liability that could arise from the release and disclosure of the information or records. This agreement shall remain in effect for a limit of one year from the date signed unless otherwise stated. Additionally, a photocopy or fax of this authorization is as valid as the original.

This authorization can be canceled upon the patient's written request,; however, any disclosures already made before receiving the patient's request will not receive any effects. In addition, we have no control over how the agency/person authorized to receive this information under this consent chooses to utilize it.
Signature of Patient (Legal Guardian/Representative)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship

8703 Meadowcroft Dr. Houston, TX 77063	P# 713-840-7956 Fax:281-972-8349
Email: admin@synergiquehealing.com	https://synergiquehealing.com/

Should be Empty:

Authorization To Disclose Or Release of Record