If you wish to authorize verbal communications only regarding your health information, please contact your clinician’s office or notify your clinician during your next appointment.

Patient Information

Specially Protected Information

I understand that my medical record may contain information that is specially protected by law. I understand that if my medical record contains such information and I do not authorize its disclosure. Prescribed Wellness Psychiatry may be unable to fulfill my request.

Expiration & Revocation

This Authorization will expire on the date that is five (5) years from the date of my signature below. I understand that I may revoke this Authorization at any time by notifying Prescribed Wellness Psychiatry in writing, except to the extent Prescribed Wellness Psychiatry has already acted in reliance on this Authorization.

Patient Signature

I have read this Authorization and authorize Prescribed Wellness Psychiatry to disclose the information identified above. I understand that Prescribed Wellness Psychiatry cannot condition my treatment, payment, enrollment or eligibility for benefits on my provision of this Authorization. I understand that information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer protected under federal law. I understand that I have the right to receive a copy of this Authorization.

Name of Consent Signer

Please enter the name of the individual who will be signing this Authorization:

(Personal Representative Signature: If you are not the patient and are signing this Authorization, please indicate your authority to sign on behalf of the patient below. You may be required to provide supporting legal documentation evidencing your authority.)