Authorization for Release of Information to Primary Care Provider Patient Legal Name* First Last Date of Birth* MM slash DD slash YYYY Email PhoneTreating Provider* Send information about my initial treatment plan to my Primary Care Provider for continuing care. Coordinate with my Primary Care Provider as necessary for care. Do not send my treatment information to my Primary Care Provider/I do not have a Primary Care Provider. Nystrom & Associates, LTD. and Family Support Services INC. (All Locations) may RELEASE to and RECEIVE the above information from:Primary Care Provider/Clinic* Primary Care Provider/Clinic Representative’s relationship to patient (parent, guardian, etc.) (See 45CFR § 164.508(c)(1)(vi))Name (If not signed by patient) NOTE: If signed by someone other than the patient, we need written proof of authority.Comments/NotesSignatureI understand the following: See CFR §164.508(c)(2)(i-iii) a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released according to this authorization. b. The information released in response to this authorization may be re-disclosed to other parties. c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization. d. Communications resulting from this authorization will reveal I have received services from NAL/FSSI. e. My health information is protected by federal regulations and state laws. Disclosure is only allowed with my authorization, except in limited circumstance as described in NAL/FSSI Privacy Policy. f. I have the right to inspect and receive a copy of my treatment records that may be disclosed to others, as provided under applicable state and federal laws. A photocopy of this authorization will be treated in the same manner as the original. Unless otherwise indicated, this authorization shall be in force and effect until 1 year from date of execution at which time this authorization expires.Consent* By checking this box, I attest that I am the individual identified above. I agree my electronic signature is the legal equivalent of my manual signature on this form.Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
