{"id":403,"date":"2026-06-24T17:01:18","date_gmt":"2026-06-24T17:01:18","guid":{"rendered":"https:\/\/weblvy9.lat\/?page_id=403"},"modified":"2026-06-24T17:59:49","modified_gmt":"2026-06-24T17:59:49","slug":"release-of-information-consent-form","status":"publish","type":"page","link":"https:\/\/weblvy9.lat\/?page_id=403","title":{"rendered":"Release Of Information Consent Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"403\" class=\"elementor elementor-403\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-19e0d91 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"19e0d91\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-2324dee\" data-id=\"2324dee\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-837d84f elementor-widget elementor-widget-heading\" data-id=\"837d84f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Critical Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-a2a3fd8\" data-id=\"a2a3fd8\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t<div class=\"elementor-element elementor-element-4afff55 e-flex e-con-boxed e-con e-parent\" data-id=\"4afff55\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-74a71cf e-con-full e-flex e-con e-child\" data-id=\"74a71cf\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-e0cb4cb e-con-full e-flex e-con e-child\" data-id=\"e0cb4cb\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-8c93145 elementor-widget elementor-widget-html\" data-id=\"8c93145\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t\t<style>\n.tc-form-container{\n    max-width:1200px;\n    margin:0 auto;\n}\n\n.tc-form-container .tc-form-wrapper{\n    font-family:Arial,sans-serif;\n    background:#fff;\n    padding:40px;\n    border:1px solid #ddd;\n    color:#000;\n    box-sizing:border-box;\n}\n\n.tc-form-container .center{\n    text-align:center;\n}\n\n.tc-form-container h1{\n    margin:0;\n    font-size:30px;\n    font-weight:700;\n}\n\n.tc-form-container h2{\n    margin:10px 0;\n    font-size:24px;\n}\n\n.tc-form-container h3{\n    margin:25px 0 15px;\n    font-size:20px;\n}\n\n.tc-form-container .row{\n    margin:20px 0;\n    line-height:1.8;\n}\n\n.tc-form-container .line{\n    display:inline-block;\n    border-bottom:1px solid #000;\n    min-width:250px;\n    height:18px;\n}\n\n.tc-form-container .small{\n    min-width:140px;\n}\n\n.tc-form-container .longline{\n    border-bottom:1px solid #000;\n    height:24px;\n    margin:12px 0;\n}\n\n.tc-form-container .checkbox{\n    margin:18px 0;\n}\n\n.tc-form-container .sig-grid{\n    display:grid;\n    grid-template-columns:1fr 1fr 1fr;\n    gap:25px;\n    margin-top:40px;\n}\n\n.tc-form-container .sig-line{\n    border-bottom:1px solid #000;\n    height:35px;\n}\n\n.tc-form-container .sig-label{\n    text-align:center;\n    margin-top:6px;\n}\n\n.tc-form-container .buttons{\n    text-align:center;\n    margin-top:30px;\n}\n\n.tc-form-container .btn{\n    padding:12px 25px;\n    border:none;\n    border-radius:4px;\n    cursor:pointer;\n    color:#fff;\n    font-size:15px;\n    margin:0 5px;\n}\n\n.tc-form-container .print{\n    background:#5b6ee1;\n}\n\n.tc-form-container .pdf{\n    background:#d9913b;\n}\n\n@media print{\n\n    body *{\n        visibility:hidden !important;\n    }\n\n    #printableForm,\n    #printableForm *{\n        visibility:visible !important;\n    }\n\n    #printableForm{\n        position:absolute;\n        left:0;\n        top:0;\n        width:100%;\n        background:#fff;\n    }\n\n    .buttons{\n        display:none !important;\n    }\n}\n<\/style>\n\n<div class=\"tc-form-container\">\n\n<div id=\"printableForm\" class=\"tc-form-wrapper\">\n\n<div class=\"center\">\n<h1>Total Care Behavioral Services<\/h1>\n<p>4396 Lawrenceville Road, Suite 101, Loganville, GA 30052<\/p>\n<p>Office Number: 678-830-2307 | Fax Number: 678-830-2511<\/p>\n<h2>CONSENT TO RELEASE \/ RECEIVE CONFIDENTIAL INFORMATION<\/h2>\n<\/div>\n\n<div class=\"row\">\nI <span class=\"line\"><\/span> Date of Birth <span class=\"line small\"><\/span>\nauthorize Total Care Behavioral Services to release and\/or obtain protected health information on my behalf.\n<\/div>\n\n<h3>Check All That Apply<\/h3>\n\n<div class=\"checkbox\">\n\u2610 Receive my medical history information from the following physician \/ healthcare provider:\n<div class=\"longline\"><\/div>\n<div class=\"longline\"><\/div>\nFax Number: <span class=\"line small\"><\/span>\n<\/div>\n\n<div class=\"checkbox\">\n\u2610 Release my treatment information \/ records to the following physician \/ healthcare provider:\n<div class=\"longline\"><\/div>\n<div class=\"longline\"><\/div>\nFax Number: <span class=\"line small\"><\/span>\n<\/div>\n\n<div class=\"checkbox\">\n\u2610 Release my treatment information to the health insurance company or employer listed below for billing or disability reporting purposes:\n<div class=\"longline\"><\/div>\n<div class=\"longline\"><\/div>\nFax Number: <span class=\"line small\"><\/span>\n<\/div>\n\n<h3>Information To Be Released<\/h3>\n\n<p>\n\u2610 Complete Medical Record<br>\n\u2610 Psychiatric Evaluation<br>\n\u2610 Progress Notes<br>\n\u2610 Medication Records<br>\n\u2610 Treatment Plan<br>\n\u2610 Laboratory Results<br>\n\u2610 Other: __________________\n<\/p>\n\n<h3>Authorization Statement<\/h3>\n\n<p>\nI 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.\n<\/p>\n\n<p>\nI 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.\n<\/p>\n\n<div class=\"sig-grid\">\n\n<div>\n<div class=\"sig-line\"><\/div>\n<div class=\"sig-label\">Patient Signature<\/div>\n<\/div>\n\n<div><\/div>\n\n<div>\n<div class=\"sig-line\"><\/div>\n<div class=\"sig-label\">Date<\/div>\n<\/div>\n\n<div>\n<div class=\"sig-line\"><\/div>\n<div class=\"sig-label\">Parent \/ Guardian Signature<\/div>\n<\/div>\n\n<div>\n<div class=\"sig-line\"><\/div>\n<div class=\"sig-label\">Parent \/ Guardian Name (Print)<\/div>\n<\/div>\n\n<div>\n<div class=\"sig-line\"><\/div>\n<div class=\"sig-label\">Date<\/div>\n<\/div>\n\n<div>\n<div class=\"sig-line\"><\/div>\n<div class=\"sig-label\">Witness Signature<\/div>\n<\/div>\n\n<div>\n<div class=\"sig-line\"><\/div>\n<div class=\"sig-label\">Witness Name (Print)<\/div>\n<\/div>\n\n<div>\n<div class=\"sig-line\"><\/div>\n<div class=\"sig-label\">Date<\/div>\n<\/div>\n\n<\/div>\n\n\n\n<\/div>\n<div class=\"buttons\">\n    <button class=\"btn print\" onclick=\"window.print()\">Print Form<\/button>\n\n    <button class=\"btn pdf\" onclick=\"downloadForm()\">\n        Download Form\n    <\/button>\n<\/div>\n\n<script>\nfunction downloadForm() {\n\n    const content =\n        document.getElementById('printableForm').outerHTML;\n\n    const html =\n        '<!DOCTYPE html><html><head><meta charset=\"UTF-8\"><title>Total Care Consent Form<\/title><\/head><body>' +\n        content +\n        '<\/body><\/html>';\n\n    const blob = new Blob(\n        [html],\n        {type:'text\/html'}\n    );\n\n    const link = document.createElement('a');\n\n    link.href = URL.createObjectURL(blob);\n\n    link.download =\n        'Total-Care-Consent-Form.html';\n\n    document.body.appendChild(link);\n\n    link.click();\n\n    document.body.removeChild(link);\n}\n<\/script>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-c9ee20c e-con-full e-flex e-con e-child\" data-id=\"c9ee20c\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>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 \u2610 Receive my medical [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-403","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/weblvy9.lat\/index.php?rest_route=\/wp\/v2\/pages\/403","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/weblvy9.lat\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/weblvy9.lat\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/weblvy9.lat\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/weblvy9.lat\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=403"}],"version-history":[{"count":22,"href":"https:\/\/weblvy9.lat\/index.php?rest_route=\/wp\/v2\/pages\/403\/revisions"}],"predecessor-version":[{"id":427,"href":"https:\/\/weblvy9.lat\/index.php?rest_route=\/wp\/v2\/pages\/403\/revisions\/427"}],"wp:attachment":[{"href":"https:\/\/weblvy9.lat\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=403"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}