Patient First Name(Required)

Patient Last Name(Required)

Date of Birth(Required)

CONSENT FOR TREATMENT:

Permission is hereby given for any drug or laboratory test, medication, or exam as may be deemed necessary by the Psychiatrist, Physician Assistant, or Nurse Practitioner.
I understand I have the right to see a Psychiatrist if I so choose and have the right to see a Psychiatrist prior to any prescription drug or device order being carried out by an Advanced Practitioner.
In the case of an un-emancipated minor, the consent below is being given on his or her behalf

CONSENT TO RELEASE MEDICAL INFORMATION TO A SPOUSE, FAMILY MEMBER OR SIGNIFICANT OTHER:(Required)

I DO NOT want to authorize information to be released to anyone but myself.

I DO want to authorize information to be released to the following:

Tell us with whom we may discuss your protected health information:

Name

Relation

Name

Relation

Name

Relation

Name

Relation

Emergency Contact

Who may we contact in case of emergency?

Name of Emergency Contact

First Last

Phone Number of Emergency Contact

Relation to patient:

Acknowledgement of Privacy Rights:

By signing below, I acknowledge that I am aware of Bridgepoint’s Notice of Privacy Practices and Individual Rights. We may use or share your medical information with personnel involved in your care at Bridgepoint. We may disclose your medical information to people outside of the system, such as Health Information Exchanges. Bridgepoint’s Notice of Privacy Practices contains more information about the policies and practices protecting the patient’s privacy. I acknowledge that I have read the above, am giving my consent to the above, and am acknowledging I have been informed of my rights to privacy.

Print Name(Required)

Email(Required)

Today's Date(Required)

Annual Consent & Authorization Form

CONSENT FOR TREATMENT:

Emergency Contact

Acknowledgement of Privacy Rights:

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