Release Receive

100 Horizon Center Blvd, 1st and 2nd floors
Ewing Mental Health LLC
Hamilton, New Jersey 08691
609 439 4351

CONSENT TO RELEASE/RECEIVE CONFIDENTIAL INFORMATION

I (Your name)

First Last

authorize Dr. Ursula Odimara at the above address to:

PATIENT DATE OF BIRTH

Receive my medical history information from the following physicians:

Receive my medical history information from the following physicians:

NAME

ADDRESS

NAME

ADDRESS

Receive my medical history information from the following physicians:

Receive my treatment records from the following therapist:

THERAPIST NAME

THERAPIST ADDRESS

Receive my medical history information from the following physicians:

Release my treatment information/records to the following healthcare professionals:

NAME

ADDRESS

NAME

ADDRESS

Receive my medical history information from the following physicians:

Release my treatment information to the health insurance company listed below for billing / authorization purposes.

INSURANCE PROVIDER NAME

INSURANCE PROVIDER ADDRESS

Receive my medical history information from the following physicians:

This information is for the following purposes (any other use is prohibited).

I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken in reliance on it. This consent will last while I am being treated by the physician specified above unless I withdraw my consent during treatment. This consent will expire 5 years from date of signature.

I understand that the records to be released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illness. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient.

I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights.

PATIENT NAME

Date

Signature

PARENT/GUARDIAN NAME

Date

Signature

WITNESS NAME

Date

Signature

Iconic Health Services offers in-person and online services for prescriptions, medication, telepsychiatry, and combined psychotherapy to residents of New Jersey.

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