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