Release of Information Form

Patient or Parent/Guardian First Name(Required)

Patient or Parent/Guardian Last Name(Required)

Email(Required)

Today's Date(Required)

I hereby authorize Bridgepoint Clinic to release and/or obtain information from the records of:

Patient First Name(Required)

Patient Last Name(Required)

Date of Birth(Required)

For the purpose/s of:

Psychiatric Evaluation

Medication Evaluation

Ongoing Treatment

Insurance Request/Claims

The information to be released and/or obtained includes all or some of the following:

1. Communication and information provided from one of your existing medical providers
2. Psychological Testing Reports
3. Medical/Surgical Records
4. School Records
5. Lab/Imaging Reports
6. Juvenile Court Records
7. Other social agency reports

Release/Obtain information to/from:

Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

PLEASE FORWARD INFORMATION TO THE ATTENTION OF BRIDGEPOINT CLINIC.

Authorization will remain in effect for:(Required)

One year or until an earlier date

The time necessary to complete my treatment

Duration of court mandate

Authorization in effect dates:

Court mandate dates:

I understand that in order to protect confidentiality, my agreement to obtain and/or release information is necessary and this permission is limited for the purposes and to the person listed above. I also understand that unless otherwise limited by state or federal regulations (such as court mandate) I can cancel this consent at any time, except for action, which has already been taken.

I hereby authorize Bridgepoint Clinic to release and/or obtain information from the records of:

The information to be released and/or obtained includes all or some of the following:

Release/Obtain information to/from:

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