Outside Provider Consent Form

Authorization for Disclosure of Clinical Information to Outside Provider

Please correct the errors described below.

I authorize Pediatrics at Newton Wellesley, P.C. to communicate with the following providers, as needed, to help with evaluation, treatment planning and coordination of care:

Pediatrics at Newton Wellesley, P.C. has my permission to release information/records acquired in the course of ongoing mental health assessment, evaluation and/or treatment of the above named patient, including telephone contact and email.

*HIV and Substance Abuse information is protected under federal law and must be authorized specifically in order to be use/disclosed

This authorization will expire with the completion of treatment, unless otherwise changed and/or revoked. I understand that I may revoke this consent at any time, and that I must notify Pediatrics at Newton Wellesley, P.C. in writing. I understand that such a revocation does not affect any action taken by Pediatrics at Newton Wellesley, P.C. prior to receiving my written notice.

Your information will be encrypted.