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Patient Information: I give permission to release the Psychotherapy Notes of: (One patient per form)
Patient Name: ____________________________________________ Date of Birth: __________________________________
Street Address: ___________________________________________ MR# or last 4 numbers of ________________________
City, State, Zip: ___________________________________________ Telephone: ( ) ______________________________
Email address: _________________________________________________________________________________________________________
Release Information From:
__________________________________________________________
(List applicable Facility(s) and/or Practice(s)
__________________________________________________________
__________________________________________________________
(Phone number)
Release Information To:
_________________________________________________________
(Name of facility, person, company) (Relationship)
_________________________________________________________
(City, State, Zip Code)
_________________________________________________________
(Phone number) (Fax number)
PURPOSE OF RELEASE (check reason): Request of individual/personal Continued patient care Insurance
Legal purpose including discussions & proceedings Other_____________________________________________________
Fill in the dates of therapy sessions for Psychotherapy Notes to be released:
Dates of therapy sessions:
From: ________________________________________ To _________________________________________
FORMAT: (Check all that may apply)
CD (charges may apply)
Paper copy (charges may apply)
Other_____________________
DELIVERY METHOD:
Reg.US Mail Pick-up Fax, where permitted
Overnight/Express Mail Service, where permitted
Secure email, where permitted
Other: ________________________________________________
PATIENT’S RIGHTS – I understand that:
I can cancel this permission at any time. I must cancel in writing and send or deliver cancellation to releasing facility
or practice named above. Any cancellation will apply only to information not yet released by the facility or practice.
This is a full release which may include information related to behavioral/mental health, drug and alcohol abuse
treatment (in compliance with 42 CFR Part 2), genetics, HIV/AIDS, and other sexually transmitted diseases.
Once my health information is released, the recipient may disclose or share my information with others and my
information may no longer be protected by federal and state privacy protections.
Refusing to sign this form will not prevent my ability to get treatment, payment, enrollment in health plan, or
eligibility for benefits.
CHS will not share or use my health information without my permission other than by ways listed in CHS’s Notice of
Privacy Practices or as required by law. The Notice of Privacy Practices is available at carolinashealthcare.org
A fee may be charged for providing the protected health information.
I have a right to receive a copy of this form upon request.
This permission expires one year after the date of my signature unless an earlier date or event is written here: ____________
Signature: _________________________________Print Name: ___________________________________Date:______________
Note: if the patient lacks legal capacity or is unable to sign, an authorized personal representative may sign this form.
Note the relationship/authority if signature is not that of the patient: (Written Proof May be Requested)
Healthcare Agent/POA Guardian Executor/Administrator/Attorney in Fact Spouse
Parent Adult Child Affidavit Next of Kin Other: ______________________________
Note: If minor consented for their outpatient treatment for pregnancy, sexually transmitted disease or behavioral/mental
health without parental consent, the minor must sign this authorization. When the patient is a minor being treated for
substance abuse, the minor must sign this authorization, regardless of who consented for treatment.
Signature of Minor:____________________________________Print Name: _________________________________Date: __________________
Authorization given to patient / Date of release: via Mail Fax Other ID Verified DL/Other ID_______
CHS
Employee
Name
&
Title:
CHS
Employee
Signature:
Date_______________
*905*
Carolinas HealthCare System
AUTHORIZATION FOR RELEASE
OF PSYCHOTHERAPY NOTES
Patient Information or Sticker
Name:
DOB:
Medical Record #: