Consent to Release Psychiatric / Medical / Alcohol / Drug Abuse Records

Eclipse Mental Health Services

Dr. Dustin O. Hayes D.O.

Patient Name:

Date:

Birth Date

hereby authorize Dustin O. Hayes D.O., to have bilateral exchange of information that is contained in my medical record with:

under the conditions listed below

1. This information will be limited to:

Psychiatric/medical/alcohol/drug abuse evaluation.

Psychiatric/medical/alcohol/drug abuse discharge summary.

Progress notes.

Psychotherapy notes.

Lab studies.

Medical tests/studies

Psychological testing.

Educational testing.

Other

If other, describe

2. Purpose or need for such disclosure

Continuing care/ Treatment, and/or

3. This consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon. If not previously revoked, this consent will terminate upon

(Specific Date, Event or Condition)

4. An additional consent must be obtained for any other transfer or disclosure of this information.

5. I understand that I may receive a copy of this release.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature

Date

Signature of Parent, Guardian or other Person authorized by law to sign in lieu of Patient.

(where required indicate which)

Date

Witness (if applicable)

Date

Your information will be encrypted.