2869 Wilshire Drive., Suite 203, Orlando, FL 32835 ~ Phone: 407-903-9696 ~ Fax: 407-903-9698 ~ Email: info@orlandopsychiatrist.net
Providing Behavioral Health Care Since 2005
Required by the Health Insurance Portability and Accountability Act --- 45 CFR Parts 160 and 164
I hereby Authorize: Syeda N. Sultana, M.D. Psychiatric Clinic .Net Board Certified Adult & Child/Adolescent Psychiatrist Tel: 407-903-9696 Fax: 407-903-9698 psychiatricclinic.net To:
The information requested or authorized for release or exchange pertains to: a. Mental Health b. Education c. HIV/Transmitted disease d. Drug or alcohol abuse This authorization is valid for 90 days from the date below. I may cancel this authorization by signing, dating and writing “CANCEL” on this original form or by sending a written, signed and dated request to the doctor above indicating my desire to cancel. I understand that once my information has been released, the recipient might re-disclose it; my doctor has no control over it and privacy laws may no longer protect it. The purpose of this authorization is to improve the quality of my health evaluation and/or treatment.
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