Authorization for Release of Confidential Information

MILESTONE PSYCHIATRIC & PSYCHOLOGICAL SERVICES, P.C.
 
1151 Pittsford Victor Rd Ste. 103 Pittsford, NY 14534 (p) 585-593-9815 (f) 607-324-9744
3460 Riverside Drive, PO Box 55 Wellsville NY 14895 (p) 585- 593-1859 (f) 585-593-5463
2438 Constitution Ave. Olean, NY 14760 (p) 716-372-9344 (f) 716-372-9497
15 Pleasant St. Hornell, NY 14843 (p) 607-324-9240 (f) 607-324-9744
 
Authorization for Release of Confidential Information
 

First Name

 

Last Name

 

Email

 

Date of Birth

 

Authorize at Milestone PPS, PC: 15 Pleasant St. Hornell, NY 14843

 

Release Information Obtain Information From Exchange Information With

 
Person/organization receiving/communicating the information:
 

Name

 

Address

 

Phone

 

Fax

 
Description of Information to be received/disclosed (check all that apply):
 

Psychological/social assessment Psychiatric evaluation Treatment Plans Progress Notes Discharge Summaries Subpoena or legal process Worker's Compensation Claim Disability Claim Medical History Lab, Radiology reports Juvenile, Justice reports Social Services records Verbal Communication Written Communication Other

 

Dates Records to be disclosed: to All

 

Purpose of Release: Evaluation Continuity of Care Medical History Other

 
One Time Use/Disclosure: I authorize the one-time use or disclosure of the information described above to the destination identified herein. My authorization will expire:
 
When acted upon
90 Days

Other

 
Periodic Use/ Disclosure: I authorize the periodic use or disclosure of the information described above to the destination identified herein. My authorization will expire:
 
When I am no longer receiving services from above identified person/ organization/ facility/ program
One year from the date signed

Other

 

I understand that this authorization is voluntary. Prohibited Disclosure: I understand that my health information may be protected by the Federal Regulations for Privacy of Individually Identifiable Health Information (Title 45 if the Code of Federal Regulations, Parts 160, and 164) For Alcohol and Drug Abuse this information is protected by federal l confidentiality rules (42 CFR, Part 2). The federal rules prohibit making any 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 is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. I understand that I may revoke this consent at any time except that action has been taken in reliance on it (e.g. probation, parole, etc) and that in any event this consent expires automatically as described above. I also understand that I may inspect and upon payment of the usual fee, receive a copy of the released information and I may receive a copy of this consent form. (A copy or facsimile of this authorization shall be as valid as the original).

 

PROHIBITION ON CONFIDENTIALITY: I understand mental/physical health professionals and teachers must report child sexual/physical abuse and neglect, threats of suicide and threats of bodily harm to others.

 

Signature
 
Date

 

Witness
 
Date

 

Parent/Guardian
 
Date

 

Relationship to Patient

 
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