Release of Information


Michael D. McGee, M.D.

Tel: 978 360 6071

Board Certified, General Adult Psychiatry, Addiction Psychiatry and Psychosomatic Medicine

Fax: 877 399 5883

PO Box 545, Avila Beach, CA 93424

Email: mdm@wellmind.com


Authorization to Release Medical Records and Verbally Share Protected Health Information

 

Patient Name:

DOB:

Street Address:

Phone #:

City, State, Zip Code:

 

I authorize Dr. McGee to release all of my Protected Health Information (PHI—to include HIV/AIDS results and drug or alcohol abuse information protected by Federal Regulation 42CFR) and to discuss my treatment with the following provider:

 

Provider/Other:

Provider/ Other Role:

Phone #:

Fax #:

Street Address:

City, State, Zip Code:

 

I understand that consent is subject to revocation at any time in writing to Dr. McGee, except if medical records or verbal information have already been disclosed. I understand that if health information is disclosed by this authorization, it may no longer be protected under the terms of the privacy rules and the recipient may be able to legally re-disclose the health information to others. I have carefully read and understand the above statements. I hereby release Dr. McGee from all legal responsibility or liability from the disclosure of PHI either in my medical records or verbally. I wish for this authorization to remain in place for the duration of my treatment and beyond until such time as I have revoked this authorization in writing to Dr. McGee.

 


 

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General Adult Psychiatry, Michael D. McGee https://wellmind.com
Signature Certificate
Document name: Release of Information
Unique Document ID: b5ffe23402f56f26b0068cf90ecd65f2da8b075f
Timestamp Audit
2016-02-15 14:41:26 ESTRelease of Information Uploaded by Michael McGee Callahan - info@wellmind.com IP 198.8.80.78