PsychotherapyForWomen.com  Vicki Bonnell, LCSW

AUTHORIZATION TO RELEASE MEDICAL IMFORMATION

Patient Name________________________________________

DOB:___/___/___ Phone#__________________ Email______________________

Authorization:

I authorize Vicki Bonnell Licensed Clinical Social Worker to request and/or release the disclosure of the protected health information to/from the following individuals/organizations:

Name of Relative/Practice/Provider:______________________________________________

Address:_____________________________City____________State______Zip_________

Phone#___________________Email__________________________

Effective Period Dates from ___/___/___  to ___/___/___ 

_____All Medical Records                 _____Diagnostic Evaluation Report

_____Lab Reports                              _____Treatment Summary Report

_____History & Physical                 _____Radiology Reports

_____Consultation Reports          _____Operative Report.    Other______

Name of Relative/Practice/Provider_____________________________________________

Address______________________City_______State_____Zip__________

Phone#___________________Email__________________________

Effective Period Dates from ___/___/___  to ___/___/___ 

_____All Medical Records              _____Diagnostic Evaluation Report

_____Lab Reports                            _____Treatment Summary Report

_____History & Physical                 _____Radiology Reports

_____Consultation Reports          _____Operative Report.    Other______

Please forward copies to: Vicki Bonnell LCSW. Email: vickibonnell2@gmail.com

I understand that my records are protected by the federal Confidentiality Regulations as well as the provisions of HIPAA and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I have the right to revoke this authorization in writing any time. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Patient Signature_______________________________Date___/___/___