Consent for Care Coordination

Harmonious Mind (Psychiatric and Counseling Services)

5189 W. Woodmill Dr., St.30, Wilmington, DE 19808. On the Web: www.HarmoniousMind.com

Tel: 302.633.6001 Fax: 302.295.6289 SMS/Text: 302.565.4818 Email: Support@HarmoniousMind.com

Patient's Full Name

Date of Birth

Name of Guardian

I confirm that I have the legal right to give this consent.

I hereby authorize Harmonious Mind to: (you may pick more than one option)

Release Records to

Person/Party name

Obtain Records from

Person/Party name

Communicate with

Person's name

the following program, person, agency

Name of Person/Program/ Agency - OK to communicate, release/obtain all info with the above name.

Phone Number

Fax to:

Email to :

the following information-check one option

all clinical information including but not limited to SOAP and progress notes, medication lists, consults, referrals, test results, information pertaining to the treatment of drug and alcohol abuse, mental illness, acquired immuno-deficiency syndrome (AIDS), or human immuno-deficiency virus (HIV), sexually transmitted diseases, tuberculosis, hepatitis C or Genetic Testing Other- Specific information only

diagnosis only, billing only, medication list only, letter only.

If Other, Please specify - What to Release or Obtain?

Purpose of Releasing or Obtaining my information:

for Coordination of Care Other

please give details-for school, for employer, for court, for disability

If Other - Please Specify - Purpose for Releasing/Obtaining

NOTE: Treatment is not conditioned by having to sign this consent. This information has been disclosed to the abovenamed recipient from records protected under Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 CFR parts 160 & 164. The information specified above will be disclosed pursuant to this authorization, and the recipient of the information may re-disclose the information, which may no longer be protected by the HIPAA privacy law. This consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon. To revoke this consent, the request must be done in writing to: Sanjay Wadhwa at the address on the top of this page.

This Consent expires on:

(If no date is given, this authorization expires 3 months after discharge from care at Harmonious Mind, LLC)

Enter Name of Patient/Guardian as Signature

Date Completed

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