Sound Mind Mental Health LLC Authorization for Release of Protected Health Information

Form Introductory Text

Patient Information: Name:*

Email*

Date of Birth

Phone Number ✓ Valid

Address

I, the undersigned, authorize Sound Mind Mental Health LLC to:(Please check one or both options)

Release my medical information to: Obtain my medical information from:

Recipient Information:

Name/Organization

Address

Phone Number ✓ Valid

Fax Number

Information to be Released (Check all that apply)

Complete Medical Record Psychiatric/Mental Health Records Medication History Treatment Plans & Progress Notes Psychological/Psychiatric Evaluations Lab Reports Other

Specify

Purpose of Disclosure

Continuity of Care Legal Purposes Insurance Personal Use Other

Specify

Acknowledgment & Consent: I understand that my medical records may contain sensitive information, including psychiatric diagnoses, substance use history, and other confidential details. I understand that the information disclosed may be re-disclosed by the recipient and may no longer be protected under HIPAA regulations. I release Sound Mind Mental Health LLC and its staff from all legal liability that may arise from this authorization.

Signature & Date: Patient/Legal Representative Signature

Clear Signature

Patient Name

Date

For Office Use Only:

Processed by

Date

Method of Disclosure

Fax Mail In-Person Electronic

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About Us

At Sound Mind, our practice stands firmly at the intersection of science and compassion.

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Contact us

1301 York Rd, Suite 800, Lutherville, MD 21093, USA.

(443) 544-4673

info@soundmindmentalhealthllc.com