Greenlake Psychiatric Release of Information

Authorization for Release of Patient Health Care Information
Patient Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
This request is:
I hearby authorize release of medical records and discussion of my care BETWEEN:

GREENLAKE PSYCHIATRIC CARE

AND
This information should go (choose one or both)
Name of person or provider
email
example@example.com
Office/Organization
Telephone
Format: (000) 000-0000.
Fax
I authorize the above parties to communicate via email about my medical and psychiatric care.
ALL health care information in my medical record
Health care information related to the following condition/dates:

Conditions/dates:
Other: (X-ray or test results, billing information, etc)

Other
Conversation, Communication and coordination between providers of my health care
Released information may include the following unless marked "NO":
HIV / AIDS related information or testing
Mark "NO" if you do not want to release information
Sexually Transmitted Disease
Mark "NO" if you do not want to release information
Mental health care or treatment
Mark "NO" if you do not want to release information
Drug and/or alcohol use
Mark "NO" if you do not want to release information
Which information should NOT be released
Reason for release
Date or situation release ends
I understand that I may inspect or copy the protected health information to be disclosed, that I may revoke this authorization in writing by contacting either of the above offices, and that information disclosed pursuant to this authorization my be subject to re-disclosure by the recipient and may no longer be protected by HIPPA.

I understand I may refuse to sign this authorization and that you will not condition treatment, payment or enrollment. However, I do need to sign to take part in a research study, for research-related treatment and to receive health care when the purpose is to create health care information for a third party.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed name if signed by guardian
Relationship
Confidential Heath Information Fax

This message is intended only for the person listed above. If the reader of this fax is not the intended recipient or this transmission is received in error, please notify us and shred this information. Thank you for your assistance.
Should be Empty: