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SCPC TMS PATIENT FORMS

Please complete the forms below and submit one day prior to your appointment.
If you have any questions, please call us at (858) 666-0212

AUTHORIZATION FOR RELEASE OF INFORMATION

Patient Name
Patient Email
Patient Phone
I hereby authorize to release

a. All psychiatric records

b. Letter to
Date

c. Verbal
d. Other


To

Recipient’s Name
Address
Phone Number
Recipient’s relationship to patient
Regarding
Purpose of release

This authorization for use or disclosure of medical information, is being authorized by me giving SCPC permission to disclose mental health/psychiatric records and information obtained in the course of the diagnosis and/or treatment of my child or me. I understand that the information disclosed pursuant to this authorization might be re-disclosed by recipient and may no longer be protected by the Federal Privacy Regulation 145 CFR Part 1641. This disclosure of medical/psychiatric information compiles with the terms of the Confidentiality of Medical Information Act 1981, section 56, et Seq. California Civil Code

     
If my consent to this information is limited, the limitation is written here:

I may revoke this authorization at any time, in writing, except to the extent action has been taken in reliance upon this consent.

Date
Signature
      Please click here to download a blank form.