Nathan
H. Azrin, Ph. D. á
Victoria Besalel Azrin, Ph. D.
A
& B Psychology Clinic
5151 Bayview Drive
Fort Lauderdale, FL 33308
Voice: (954) 491-6984 á Fax
(954) 491-7068
Patient Name:
___________________________________ Date of Birth: ___________________
Social Sec.
#__________________________ Date(s) of requested records: _________________
I hereby authorize the
above providers to obtain and release the protected information specified
below.
Please list any restrictions
on this release of information__________________________________________________
Name____________________________ Phone_________________ Fax_______________
Address___________________________________________________________________
City State Zip
Name____________________________ Phone_________________ Fax_______________
Address___________________________________________________________________
City State Zip
Name____________________________ Phone_________________ Fax_______________
Address___________________________________________________________________
City State Zip
Name____________________________ Phone_________________ Fax_______________
Address___________________________________________________________________
City State Zip
Name____________________________ Phone_________________ Fax_______________
Address___________________________________________________________________
City State Zip
Records to be Obtained: Please send copies of all EEG, MRI, CT, History and
Physical, and the doctors last progress notes.
Release: This form when completed and signed by you, authorizes
me to release, as well as obtain, protected information from your clinical
record to and from the person(s) you designate. I hereby authorize Dr. Nathan
H. Azrin and Dr. Victoria A. Besalel and/or his or her administrative and
clinical staff to release any and all contents of my chart (including at least
billing information, psychotherapy/progress notes, test results/data, reports,
visit information, prescriptions, medical information, documents provided by
patient, insurance/third party forms/reports, records received by others). This
information should only be released to and/or obtained from the above
individuals.
I am requesting my psychologist,
psychiatrist, or social worker release this information to aid in treatment
and/or assessment and/or provide information about me to others. This authorization shall remain in
effect indefinitely. However, you
have the right to revoke this authorization, in writing, at any time by sending
such written notification to my office address. However, your revocation will not be effective to the extent
that I have taken action in reliance on the authorization or if this
authorization was obtained as a condition
of obtaining insurance coverage and the insurer has a legal right to contest a
claim.
I
understand that my psychologist,
psychiatrist, or social worker generally
may not condition psychological services upon my signing an authorization
unless the services are provided to me for the purpose of creating health
information for a third party.
I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.
I hereby release the above treatment/assessment providers and their respective medical staff and office from any and all liability and claims arising out of or relating to the disclosure and/or release of confidential and/or privileged information.
Informed Consent: I agree to participate in evaluation/treatment, and the purpose has been explained to me and/or my guardian/representative.
_________________________________ _________________________________ _________________
Name of patient and/or
responsible party Signature
of patient or responsible party Date
_________________________________________________________________________________________________
If signed by patientŐs representative, a description of representative's authority to act for the patient is provided above.
***
Please fax records to Fax# (954)
491-7068 OR call Voice #
(954) 491-6984