THEZ07 Authorization to Obtain Medical Records

Therapeutic Medical and Psychiatric Services

Diane P. Davis, APRN, FNPC, PMHNP-BC

1501 Royal Avenue

Monroe, LA 71201

P: 318-816-5116 F: 315-855-3429

AUTHORIZATION TO OBTAIN MEDICAL RECORDS
Patient Name:*

First NameMiddle NameLast Name
Patient Date of Birth:*

MonthDayYear
Date
I hereby authorize the following designated office or person of Name of Doctor or Clinicto release my medical records held in my name to: Name of Doctor or Clinic.
Please release initial evaluation, labs, plan of care, medications, progress notes, as well as any test results that may have been preformed. The release of these records to us are intended to provide ongoing treatment for the benefit of our mutual patient.

THIS AUTHORIZATION SI TO REMAIN INEFFECT FOR 90 DAYS FROM THE DATE INDICATED BELOW AND ALLOWS FOR EXCHANGE OF MEDICAL INFORMATION BY THE TELEPHONE OR OTHER DIRECT VERBAL COMMUNICATION IN LIEU OF WRITTEN COMMUMICATION IF NECESSARY.
Digital Signature Authorization*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature of Client 18 years of age and older:*

Clear
Parent or Legal Guardian Signature:

Clear
Date*

MonthDayYear
Date
FOR OFFICE USE ONLY:

__________________________________________________________________

Signature of witnessing office personnel and date
Should be Empty: