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
MENTAL HEALTH RECORDS AUTHORIZATION
(PLEASE FILL OUT COMPLETELY TO AVOID DELAY)
Please be advised that Record Requests take UP TO 30 days to process
I authorize the use/disclosure of my mental health records as follows:
This authorization becomes effective immediately and shall expire on date entered below. If no date is entered, this authorization expires 3 months after discharge of care from Harmonious Mind, LLC.
Revocation: I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Harmonious Mind, LLC at 5189 W. Woodmill Dr., Suite 30, Wilmington DE. 19808. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization. ted text
Re-disclosure of my mental health records: I understand that the person who receives my mental health records may NOT disclose it to someone else without my permission, unless permitted by law.
Effect of not signing this authorization: I am not required to sign this authorization in order to receive most health care services at Harmonious Mind, LLC. However, I understand that if the ONLY reason I am seeing a Harmonious Mind, LLC provider is to create health information for someone else's use (such as my employer or school), Harmonious Mind, LLC may refuse to see me if I do not sign this authorization.
Right to inspect & copy: I understand that I have a right to inspect and receive a copy of the records to be disclosed pursuant to this authorization.
Specially protected records: I understand that my health records may include information pertaining to the treatment of drug and alcohol abuse, mental illness, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), sexually transmitted diseases, tuberculosis, hepatitis C, or genetics testing. If you so wish, that we do Not disclose this info, enter your initials to the side.
Fees: I understand that I may be charge a processing fee to complete this request, and I may ask Harmonious Mind, LLC for a fee estimate.
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