LOSATS Consent to Disclose/Obtain Information

Questions?

We would be happy to answer any questions you may have regarding this form. Please call us at: (585) 586-6840

I, Patient or Guardian Name

Phone Number

Give permission for the disclosure and/or exchange of: (Please Check All That Apply)

Psychiatric Information

Alcohol Information

Medical/Surgical Information

Legal Information

This information is in regards to:

Date of Birth

Phone Number

This information may be: (Please Select One or Both Options)

Released to the person below

Recieved from the person below

Name of Person Releasing and/or Recieving Information

Phone Number

Address

Fax Number

Other Purpose(s) If Not Listed

Other Method(s) If Not Listed

The Information To Be Released Shall Include (Please Select All That Apply)

Assessments

Progress Notes

Psychiatric Information

Discharge Summary

Treatment Plans

History

Medical Information

Educational Information

ALL INFORMATION

Other Information If Not Listed

This consent covers treatment period(s):

From

or ALL EPISODES OF CARE

Yes

I understand that my records are protected under the Federal Regulations governing confidentiality 42CFR, Part 2 and/or New York State Mental Hygiene Law and cannot be disclosed without my written consent unless otherwise provided for in the regulations. Further release of information is prohibited by law. I also understand that I may revoke this consent in writing or verbally at any time except to the extent that action has been taken in reliance on it.

I hereby declare that I am the:

Patient Parent Legal Guardian/Representative

Patient Signature (any patient 12 or older must sign - If under 12 type NA)

Understand that by typing and submitting you understand that it is your intention to provide a legally binding signature for agreement to disclose/obtain information.

Date

Parent / Guardian / Significant Other Signature (if signed by patient type NA)

Understand that by typing and submitting you understand that it is your intention to provide a legally binding signature for agreement to disclose/obtain information.

Date

Witness Signature

Understand that by typing and submitting you understand that it is your intention to provide a legally binding signature for agreement to disclose/obtain information.

Date

This consent shall expire

90 days from date of consent One year from date of consent

Other Time Period

(Not to Exceed One Year)

Your information will be encrypted.

LOSATS Consent to Disclose/Obtain Information

Questions?

This consent covers treatment period(s):

Questions?

Linden Oaks Specialized Assessment and Treatment Services (LOSATS)