ReleaseofInfo

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					                               Georgia Mental Health & Psychiatry
                         155 Eagles Walk, Ste F, Stockbridge, GA 30281
                     Medical Records Fax (770)389-3030, Phone (770)389-8100
                              Authorization to Release Information

RE:                                        DOB                      SSN:_________________________

Print Name of Parent/Guardian (if request is for a minor)_____________________________________

I hereby request and authorize:
( )Alan Weinberg, MD       ( )Piyush Patel, MD                ( )Vandana Anand, MD
( )Marjorie Warren, MD     ( )Verona Lawson, MD               ( )Yolanda Malone-Gilbert, MD
( )Nancy Gogins, LPC       ( )Victoria Barnes, MD            ( )Susan Winfield, LPC

to release any and all information as indicated below to:

Name:                                Telephone:              Fax:_________________
Address:___________________________________________________________________________

for the following purposes:  Continuing Care and Treatment  Insurance Claim
                             Other, describe_______________________________

By initialing the spaces below, I specifically authorize the use and disclosure of the following
health information and/or medical records, if such information and/or medical records exist:

___Entire Medical Record           ___Progress Notes      ___Lab Reports       ___History/Physical Exam

___Evaluation Notes               ___Therapy Notes        ___Billing Statements

___Discharge Summary/ Notes              Other, describe____________________

I understand that if the person or entity receiving the information is not a health care provider or health
care plan covered by federal privacy regulations, the information described above may be redisclosed
and no longer protected by these regulations.

I further understand that I may refuse to sign this authorization and that my refusal to sign will not
affect my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or copy
any information to be used or disclosed under this authorization.

Finally, I understand that I may revoke this authorization in writing at any time, provided I do so in
writing, except to the extent that action has been taken in reliance upon this authorization.

______________________________                        _________________________________________
Signature of patient or legal guardian                Date

_____________________________                         _________________________________________
Signature of witness                                  Date
                                 Non-Covered services Agreement
Fees for ancillary services such as copies of medical records, reports, third-party letters, medical
leave forms, formulary questions and appeals, etc. are not covered by most insurance plan. Fees
for these services are defined by the office and are based on copy costs and the amount of time
required by clinical and administrative staff.

I understand that this is a non-covered service based upon my current insurance benefits and is
to be paid at the time of service and is not reimbursable by my insurance plan.
Signature:                                                    Date:

				
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posted:10/19/2011
language:English
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