VPC Release of Info Consent Form

Authorization to Obtain/Release Confidential Information Consent
(Patient Name)

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I , First Name Last Name ,am the patient or legal representative and authorize the Provider to
Virtual Psychiatric Care Provider*
Choose 1
Name of Person, Organization or Practice Name
Relationship
Organization Medical Records Contact Number
Format: (000) 000-0000.
Organization FAX Number (Release VPC records to)
Please enter a valid phone number.Format: (000) 000-0000.
Secure Email Address (Email VPC records to):
example@example.com
RETURN MEDICAL RECORDS TO SECURE FAX NUMBER: 954-278-9083 or Email records: Billing@VirtualPsychiatricCare.com
Description of Information to be Disclosed
Exceptions/Information Not To Be Disclosed if requested
Purpose

The purpose of this document is to allow access to information necessary to improve assessment and treatment planning, share information relevant to treatment and, when appropriate, coordinate treatment services. For other purposes, please specify:

Expiration

Unless sooner revoked, this consent is valid for a period of 12 months after consent is obtained.

Voluntary Authorization and Treatment Decisions

You understand that signing this authorization is voluntary. Your provider will not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign it. However, if necessary clinical information is unavailable, your provider may be unable to safely provide certain treatments or prescribe or continue certain medications, including controlled substances.

Form of Disclosure: Unless you have requested in writing that disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner we deem to be appropriate and consistent with applicable law, including but not limited to verbally, in paper format, or electronically.

Form of third party Request: All requests for patient information must be submitted in writing via email, fax, or paper format.

RE-DISCLOSURE

"This information has been disclosed to you from records protected by Federal Confidentiality rules (42 CFR part 2 The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information in NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse Client."

You may request a copy of this authorization for my records.

RIGHT TO REVOCATION

You may revoke this authorization at any time by submitting a written request to MiamiPsych Concierge, LLC d/b/a Virtual Psychiatric Care. My revocation will apply only to future uses or disclosures and will not affect information already used or disclosed in reliance on this authorization before my written revocation was received.

Patient or Legal Representative Signature:
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Records Release To Virtual Psychiatric Care Instructions:

1. PLEASE RETURN MEDICAL RECORDS TO SECURE FAX: 954-278-9083.

2. OR EMAIL: Billing@VirtualPsychiatricCare.com

3. Or Mail To: Virtual Psychiatric Care: Address: 1900 N Bayshore Dr, ste 1A #144, Miami, FI 33132. Contact Number 786-761-1155:
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Authorization to Obtain/Release Confidential Information Consent