Authorization To Release of Medical Information
I authorize the person/organization noted below to release/receive the information/records specified below to/
from Alpha Psychiatric Associates. This is being requested for the purpose of ongoing treatment.
The specific protected health information I am requesting to be disclosed is:
I understand that information or records sent to Alpha Psychiatric Associates may be incorporated into my
medical record and will become part of my protected health information at Alpha Psychiatric Associates. This
authorization will expire in 90 days from the date indicated below (or sooner if I revoke this in writing).
I understand that I am not required to sign this form to receive care from Alpha Psychiatric Associates.
To be filled when someone other than the patient signs:
I hereby certify that I am the duly authorized representative of the above patient and authorized to sign this
request on behalf of the above patient.
(Relationship to Patient)
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization To Release of Medical Information
Agree & Sign