Health IT Foundation

Authorization To Release of Medical Information


Patient Details

(Name)   (Date of Birth)
(Full Address)   (SSN)

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.

(Person/Org)   (Phone)
(Full Address)   (Fax)

The specific protected health information I am requesting to be disclosed is:

(Other)

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:

Signature Certificate
Document name: Authorization To Release of Medical Information
Unique Document ID: c1e02a48397edcc7245db9b41714c4ca2f55e64b
Timestamp Audit
March 31, 2019 4:52 pm EDTAuthorization To Release of Medical Information Uploaded by Front Desk - contactus@alphapsychiatry.com IP 107.15.107.168
March 31, 2019 5:36 pm EDTFront Desk - alphapsy@meditsites.com added by Front Desk - alphapsy@meditsites.com as a CC'd Recipient Ip: 107.15.107.168
March 31, 2019 5:44 pm EDTFront Desk - alphapsy@meditsites.com added by Front Desk - alphapsy@meditsites.com as a CC'd Recipient Ip: 107.15.107.168
March 31, 2019 5:47 pm EDTFront Desk - alphapsy@meditsites.com added by Front Desk - alphapsy@meditsites.com as a CC'd Recipient Ip: 107.15.107.168
March 31, 2019 5:48 pm EDTFront Desk - alphapsy@meditsites.com added by Front Desk - alphapsy@meditsites.com as a CC'd Recipient Ip: 107.15.107.168
March 31, 2019 5:50 pm EDTFront Desk - alphapsy@meditsites.com added by Front Desk - alphapsy@meditsites.com as a CC'd Recipient Ip: 107.15.107.168
March 31, 2019 5:51 pm EDTFront Desk - alphapsy@meditsites.com added by Front Desk - alphapsy@meditsites.com as a CC'd Recipient Ip: 107.15.107.168
March 31, 2019 6:00 pm EDTFront Desk - alphapsy@meditsites.com added by Front Desk - alphapsy@meditsites.com as a CC'd Recipient Ip: 107.15.107.168
March 31, 2019 6:02 pm EDTFront Desk - alphapsy@meditsites.com added by Front Desk - alphapsy@meditsites.com as a CC'd Recipient Ip: 107.15.107.168
March 31, 2019 6:08 pm EDTFront Desk - alphapsy@meditsites.com added by Front Desk - alphapsy@meditsites.com as a CC'd Recipient Ip: 107.15.107.168
March 31, 2019 6:15 pm EDTFront Desk - alphapsy@meditsites.com added by Front Desk - alphapsy@meditsites.com as a CC'd Recipient Ip: 107.15.107.168
March 31, 2019 6:16 pm EDTFront Desk - alphapsy@meditsites.com added by Front Desk - alphapsy@meditsites.com as a CC'd Recipient Ip: 107.15.107.168
March 31, 2019 6:20 pm EDTFront Desk - alphapsy@meditsites.com added by Front Desk - alphapsy@meditsites.com as a CC'd Recipient Ip: 107.15.107.168
March 31, 2019 6:32 pm EDTFront Desk - contactus@alphapsychiatry.com added by Front Desk - contactus@alphapsychiatry.com as a CC'd Recipient Ip: 107.15.107.168