Release of Information-Adult Petit Psychiatry Patient' Name:(Required) First Last Date of Birth MM slash DD slash YYYY I hereby authorize the following: Person/Facility: PETIT PSYCHIATRY Address: 6801 Lake Worth Rd Ste 213, Greenacres, Florida 33467 Phone: (561) 576 7879 FAX: (866) 450-1704 The above party may disclose health information to the following Recepient:Person/Facility(Required) AddressPhoneFaxEmail FOR THE PURPOSE OF:All of my health information.(Required) Yes No My health information related to the following treatment condition:My health information covering the date period from date to date.Other:The purpose of this authorization is (check all that apply)At my Request(Required) Yes No Coordination of care and treatment planning(Required) Yes No This authorization ends on(Required) None After 3 months Date: When the following event occurs:I. My Rights I understand that I have the right to revoke this authorization, in writing, at any time, except where my uses or disclosure have been already made based on my original request. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party. I understand that uses and disclosures already made based upon my original permission cannot be taken back. I understand that it is possible that my information used or disclosed with my permission may be redisclosed by the recipient and is no longer protected by HIPAA Privacy Standards. I understand that the treatment by any party may not be continued upon signing of this authorization (unless treatment is sought only to create health information for a third party or to take part to a research or study) and that I may have the right to refuse to sign this authorization. I will receive a copy of this authorization after I signed it. A copy of this authorization is as valid as the original.I decline to fill out the release of information.(Required) Yes No The printed name of the Patient or Authorized Representative(Required)Date MM slash DD slash YYYY Signature Or Authorized Representative(Required)
