Holistic Mental Healthcare- Intake and New Patient Registration
Consent to Release Information
I consent to the sharing of my medication records, psychiatric evaluations and treatment records, laboratory results, other medical tests, progress notes, treatment plans, evaluations, and treatment status. The purpose of this disclosure is to facilitate treatment, assessment, and case disposition.
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I understand that my medical records (including any alcohol, drug, or psychiatric information) may be protected by federal regulations. I can revoke this consent in writing at any time, except for actions already taken based on this consent. This consent expires one year after the termination of my case.
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I indemnify and hold Holistic Mental Healthcare harmless from any damages or prejudice that might result to me, my relatives, or heirs from the use or misuse of the information provided by the agency under this authorization.
Prohibition on Redisclosure: The information disclosed to you is from records protected by federal law. Federal regulations (42 CFR Part 2) prohibit further disclosure of this information without the specific written consent of the person to whom it pertains. A general authorization for the release of medical or other information held by another party is not sufficient for this purpose. Violations of these provisions can result in fines of up to $500 for the first offense and up to $5,000 for each subsequent offense.