- Demographics (Name, Address, Age, Sex and Race)
- Behavioral health services/psychiatric care.
- Diagnostic/Medical/Surgical History
- Infectious Diseases and Treatment History
- Treatment for alcohol and/or drug abuse
- Past and Current Medication Therapies
This information may be used for one or more of the following purposes:
- Medical Treatment and/or Review
- Clinical Research Review and study
- Release of Information to organizations including government agencies and for clinical research reporting.
I understand that my health information will be saved at the above referenced address in a confidential database. I understand that the physician and other authorized staff agrees not to share my confidential information, except as authorized by law.
Affirmation of Release
I authorize the above named agency and give permission to release the information indicated on this form to the individual(s) or agency(s) I have named and only for the purposes written. I understand that this release is valid for up to 15 years from the date I sign it and I may refuse to sign this authorization or revoke it at any time. Any revocation or refusal to sign this authorization will not affect my ability to obtain treatment or payment or my eligibility for benefits. The revocation will take effect when it is received in writing. As a patient I have the right to access my treatment records during ongoing treatment records during ongoing treatment and after discharge. Copies of the records may be obtained with reasonable notice and payment of copying costs.
