Consent for Release of Information -General

Authorization and Consent for Release of Information

WHO
By signing below, I authorize Thrive Behavioral Health to Thrive Behavioral Health to receive and provide information with all of the following:

To and From Medical Provider:   Enter name or N/A*        
Phone:    phone number       
Fax:   fax time   
Address:   Street Address   Address Line 2   City   State   Zip   
       
To and From Pharmacy (Required if seeing a Thrive prescriber):   Enter name or N/A*        
Phone:   phone number               
Fax:   fax number   
Address:   Street Address   Address Line 2   City   State   Zip   

To and From Previous Mental Health Provider :   Enter name or N/A*       
Phone:   phone number              
Fax:   fax number   
Address:   Street Address   Address Line 2   City   State   Zip   

To and From Previous Psychiatric Hospitalization:   Enter Name or N/A*        
Phone:   phone number                  
Fax:   fax number   
Address:   Street Address   Address Line 2   City   State   Zip   
 
To and From School:   Enter Name or N/A* 
Phone:   phone number                    

To and From Referring Person or Agency :   Enter Name or N/A*   
Phone:   phone number   


To and From Other Individual/Organization:   Enter Name or N/A* 
Relationship:         relation to client   
Phone:   phone number     

Dates of Service: Any and all, unless indicated here:   Date of Service   
WHAT
I specifically authorize the exchange of the following information (check all that apply):
✔ Medical Records   
✔ School and educational records
✔ Verbal discussion of case (including, but not limited to diagnosis, attendance, treatment progress, interventions, psychosocial history, and recommendations).   
✔ Mental Health Records including Evaluations, Individualized Treatment Plans, and Medication History   
✔ Information related to and/or including substance use, substance abuse history, assessment, treatment, progress and referrals  
✔ Information related to and/ or including HIV, AIDS, or other STD related information  
✔ Permission to provide services on school grounds, if applicable.
    
Other:            
WHY
Continuity of Care/Treatment coordination and/or:
Request
Legal purposes   
Other:       
Important Information
I understand that:

• This authorization is voluntary. My treatment will not be impacted if I do not sign this authorization. I do understand that Thrive psychiatrists or nurse practitioners are not required to prescribe medication if they determine they do not have enough information in order to make an informed medical decision.
• This authorization is valid 1 year from date signed unless otherwise indicated and specified here:    .
• I may revoke/withdrawal this authorization, except to the extent that action has been taken prior to receipt of the revocation/withdrawal, by notifying Thrive in writing of withdrawal of authorization to release information.
• Once my health information is exchanged/released, it may no longer be protected by federal law and could be disclosed by the person(s) receiving it.
• The medical information released may contain information related to HIV status, AIDS, sexually transmitted diseases, mental health drug and alcohol abuse, etc.
• Thrive Behavioral Health may provide data to partnership schools for performance improvement, research or other data related reasons.