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Critical Form

Complete the confidential information release and authorization form for Total Care Behavioral Services. Please provide all requested information accurately before signing.

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Confidential Information Protected patient information
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Complete Carefully Provide accurate information
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Print When Ready Review before signing
Consent & Authorization

Consent to Release / Receive Confidential Information

Please complete the form below to authorize Total Care Behavioral Services to release and/or obtain protected health information on your behalf.

Total Care Behavioral Services

4396 Lawrenceville Road, Suite 101, Loganville, GA 30052

Office Number: 678-830-2307 | Fax Number: 678-830-2511

CONSENT TO RELEASE / RECEIVE CONFIDENTIAL INFORMATION

I Date of Birth authorize Total Care Behavioral Services to release and/or obtain protected health information on my behalf.

Check All That Apply

☐ Receive my medical history information from the following physician / healthcare provider:
Fax Number:
☐ Release my treatment information / records to the following physician / healthcare provider:
Fax Number:
☐ Release my treatment information to the health insurance company or employer listed below for billing or disability reporting purposes:
Fax Number:

Information To Be Released

☐ Complete Medical Record
☐ Psychiatric Evaluation
☐ Progress Notes
☐ Medication Records
☐ Treatment Plan
☐ Laboratory Results
☐ Other: __________________

Authorization Statement

I understand that I may revoke this authorization at any time in writing unless action has already been taken based upon this authorization. This authorization shall expire 365 days after completion of treatment unless otherwise revoked.

I acknowledge that my records may contain information relating to mental health treatment, substance use treatment, and other confidential healthcare information protected by applicable federal and state laws.

Patient Signature
Date
Parent / Guardian Signature
Parent / Guardian Name (Print)
Date
Witness Signature
Witness Name (Print)
Date
i
Please Review Before Signing

Make sure all required information is complete and accurate before printing and signing the authorization form.

Total Care Behavioral Services  •  Reclaim your life

Critical Form

Total Care Behavioral Services

4396 Lawrenceville Road, Suite 101, Loganville, GA 30052

Office Number: 678-830-2307 | Fax Number: 678-830-2511

CONSENT TO RELEASE / RECEIVE CONFIDENTIAL INFORMATION

I Date of Birth authorize Total Care Behavioral Services to release and/or obtain protected health information on my behalf.

Check All That Apply

☐ Receive my medical history information from the following physician / healthcare provider:
Fax Number:
☐ Release my treatment information / records to the following physician / healthcare provider:
Fax Number:
☐ Release my treatment information to the health insurance company or employer listed below for billing or disability reporting purposes:
Fax Number:

Information To Be Released

☐ Complete Medical Record
☐ Psychiatric Evaluation
☐ Progress Notes
☐ Medication Records
☐ Treatment Plan
☐ Laboratory Results
☐ Other: __________________

Authorization Statement

I understand that I may revoke this authorization at any time in writing unless action has already been taken based upon this authorization. This authorization shall expire 365 days after completion of treatment unless otherwise revoked.

I acknowledge that my records may contain information relating to mental health treatment, substance use treatment, and other confidential healthcare information protected by applicable federal and state laws.

Patient Signature
Date
Parent / Guardian Signature
Parent / Guardian Name (Print)
Date
Witness Signature
Witness Name (Print)
Date