Thank you for completing the form. I look forward to seeing you soon.1 0% https://mindandbodydoctor.com/wp-content/plugins/nex-forms-litefalsemessagehttps://mindandbodydoctor.com/wp-admin/admin-ajax.phphttps://mindandbodydoctor.com/release-of-informationyes *Patient Name*Date of BirthThis form, when completed and signed by you, authorizes me to release protected information from your clinical record to the person you designate. You agree and understand that this form does not constitute a general release, and that by checking off or specifying information below you are agreeing to an informed release of specific sensitive and confidential information. I am requesting the release of this information for the following reasons: –Select– –Select– At the request of the patient or authorized representative At the request of the patient or authorized representative For treatment care coordination For treatment care coordination I authorize my psychologist, Dr. Heidi R. Cherwony to release the following information: –Select– –Select– Psychological Evaluation Psychological Evaluation Summary of Records Summary of Records All information All information Test Results Test Results Other Other If Other, please explain:This information should only be released to:: –Select– –Select– My physician My physician My psychiatrist My psychiatrist My teacher My teacher My dietician My dietician Occupational therapist Occupational therapist Physical therapist Physical therapist Other Other If Other, please explain:Name, address, email, fax and telephone number of person to whom information is to be released:This authorization shall authorize for release of information from/to:This authorization shall authorize for release of information from (Date Below) until 120 days following the termination of therapy or closure of my case or file with Heidi R. Cherwony, Psy.D, P.A. You have the right to revoke this authorization in writing at any time by sending such written notification to one of our offices. However, your revocation will not be effective to the extent that we have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. By signing below you agree to the release of the above information, that the nature of this information has been discussed with you in a manner that you understand, and that you have had an opportunity to have any questions regarding the above release of information explained to you. You are indicating that you understand that Heidi R. Cherwony, Psy.D, P.A. generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party. I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of your information, viewed by persons unknown to you, and no longer protected by the HIPAA Privacy Rule or by Federal or State law or rules. Signature of Patient or Authorized Representative *WitnessATTENTION TO AGENCIES AND/OR TO INDIVIDUALS TO WHOM THIS INFORMATION IS TO BE DISCLOSED: If you have received this information in error please contact our office as soon as possible to arrange for the return of the received material. This information may be protected from redisclosure without informed signed consent from the individual or agency to which it pertains. Do not redisclose this confidential information without signed informed consent or as otherwise allowed by law. Submit
