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1. This information will be limited to:
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Psychiatric/medical/alcohol/drug abuse evaluation.
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Psychiatric/medical/alcohol/drug abuse discharge summary.
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Progress notes.
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Psychological testing.
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Psychotherapy notes.
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Educational testing.
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Lab studies.
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Medical tests/studies.
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2.Purpose or need for such disclosure: Continuing care/ Treatment, and/or
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3.This consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon.
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If not previously revoked, this consent will terminate upon
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4.An additional consent must be obtained for any other transfer or disclosure of this information.
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5.I understand that I may receive a copy of this release.
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Patient’s Signatur
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Date
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Signature of Parent, Guardian or other Person authorized by law to sign in lieu of Patient (where required).
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Date
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Witness (if applicable)
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Date
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