Release

CONSENT TO RELEASE / RECEIVE HEALTHCARE INFORMATION

Patient Name: *

Date * +

Patient DOB *

GenPsych Location (please select one) *

Select who information should be released to/received from: *

I, request and authorize GenPsych to release/receive healthcare information to/from the following for the purposes: *

Please select if appropriate: *

Information may be released to

Information may be received from

Name of Individual I am allowing GenPsych to release/receive information to/from: *

Relationship to patient *

Address

Phone Number

Fax Number

Email Address

This request and authorization applies to: (click all applicable) *

**** GenPsych, its employees, and patients are strictly prohibited from receiving any remuneration by GenPsych or its affiliates as a direct result of this release. However release of protected health information for marketing purposes may encourage recipients’ use of the organization’s products or services.

*** Pursuant to NJAC 13:35-6.5, GenPsych reserves the right to charge $1.00 per page for medical record reproduction, or $100.00 for the entire record, whichever is less.

I understand and authorize the exchange of information as requested above.

I also understand that this release will remain in effect until I am discharged from treatment or until the following date: +

I understand that I may revoke this authorization in writing, which will take effect on the date it is received, except to the extent that GenPsych has already taken action in reliance upon my authorization, or as a condition of obtaining insurance coverage or required by applicable laws or regulations as set forth by GenPsych’s Notice of Privacy Practices. I understand that if the above-named person or entity is not a health care provider or part of a health plan covered by federal privacy regulations and this form authorizes the release of my health information, my health information may be re-disclosed by the person or entity I have named above and will no longer be protected by these regulations. However, the person or entity named above may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.

I understand that if I refuse to sign this form, GenPsych will not disclose my information to the person or entity named above, unless otherwise required by law. Furthermore, I understand that GenPsych will not condition any treatment or services on my signing this form.

Patient signature *

clear

Date * +

If Patient is under 18, Parent signature is required:

clear

Date +