Email Address: ANSWER (( Include your GTA World forum name & Discord username here. ))
II. RELEASE DETAILS
Purpose of Request:(e.g. personal use, continuation of care, legal proceedings, disability claims, etc.) ANSWER
Dates of Treatment:(provide the specific date range for which you are requesting records) ANSWER
Type of Records Requested:(e.g. treatment progress notes, therapy session summaries, medication management records, psychological assessments, substance abuse treatment plans, discharge summary, lab test results, etc.) ANSWER
Method of Delivery:
[] Mail (records will be sent to the address provided)
[] Email (records will be sent encrypted to the email address provided)
[] In Person Pickup (records can be picked up at our facility during designated hours)
[] Other: ANSWER
Recipient Information:(if the records are to be sent to a specific recipient, please provide their name, organization (if applicable), contact information, and any relevant details) ANSWER
III. AUTHORIZATION AND SIGNATURE
I, [Your Full Name], hereby authorize Valentines Rehabilitation Center to release my records as requested above. I understand that the information disclosed may include sensitive details about my health and treatment, and I consent to the release of this information for the specified purpose(s) outlined in this form.
I understand that my medical records are confidential and protected by federal and state privacy laws. I acknowledge that Valentines Rehabilitation Center will make reasonable efforts to ensure the security and privacy of my health information during the release process.
I further understand that the information disclosed may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. I release Valentines Rehabilitation Center and its staff from any liability associated with the release and subsequent use of my medical records by authorized recipients.
[divbox=#303544][center][br][/br][img]https://i.imgur.com/6WhFHLO.png[/img][br][/br][/center][/divbox][br][/br]
[divbox=#363E54][br][/br][left][color=#47AEBF][size=120][b][indent][center]I. PATIENT INFORMATION[/center][/indent][/b][/size][/color][/left][br][/br][/divbox]
[divbox=#303544][br][/br]
[list=none][b]Full Name:[/b]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Date of Birth:[/b]
[size=85][i]DD/MMM/YYYY[/i][/size][br][/br][br][/br]
[b]Gender:[/b]
[size=85][list=none]
[*][] Male
[*][] Female
[*][] Other: [i](state what here)[/i][/list][/size]
[b]Address:[/b]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Phone Number:[/b]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Email Address:[/b]
[size=85][i]ANSWER (( Include your GTA World forum name & Discord username here. ))[/i][/size][br][/br][br][/br][/list][br][/br][/divbox][br][/br]
[divbox=#363E54][br][/br][left][color=#47AEBF][size=120][b][indent][center]II. RELEASE DETAILS[/center][/indent][/b][/size][/color][/left][br][/br][/divbox]
[divbox=#303544][br][/br][list=none][b]Purpose of Request:[/b] [size=70][i](e.g. personal use, continuation of care, legal proceedings, disability claims, etc.)[/i][/size]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Dates of Treatment:[/b] [size=70][i][/i][/size] [size=70][i](provide the specific date range for which you are requesting records)[/i][/size]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Type of Records Requested:[/b] [size=70][i](e.g. treatment progress notes, therapy session summaries, medication management records, psychological assessments, substance abuse treatment plans, discharge summary, lab test results, etc.)[/i][/size]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Method of Delivery:[/b]
[list=none][size=85][*][] Mail [size=70][i](records will be sent to the address provided)[/i][/size]
[*][] Email [size=70][i](records will be sent encrypted to the email address provided)[/i][/size]
[*][] In Person Pickup [size=70][i](records can be picked up at our facility during designated hours)[/i][/size]
[*][] Other: [size=85][i]ANSWER[/i][/size][/size][br][/br][/list]
[b]Recipient Information:[/b] [size=70][i](if the records are to be sent to a specific recipient, please provide their name, organization (if applicable), contact information, and any relevant details)[/i][/size]
[size=85][i]ANSWER[/i][/size][br][/br][br][/br][/divbox][br][/br]
[divbox=#363E54][br][/br][left][color=#47AEBF][size=120][b][indent][center]III. AUTHORIZATION AND SIGNATURE[/center][/indent][/b][/size][/color][/left][br][/br][/divbox]
[divbox=#303544][br][/br][list=none]
I, [Your Full Name], hereby authorize Valentines Rehabilitation Center to release my records as requested above. I understand that the information disclosed may include sensitive details about my health and treatment, and I consent to the release of this information for the specified purpose(s) outlined in this form.
I understand that my medical records are confidential and protected by federal and state privacy laws. I acknowledge that Valentines Rehabilitation Center will make reasonable efforts to ensure the security and privacy of my health information during the release process.
I further understand that the information disclosed may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. I release Valentines Rehabilitation Center and its staff from any liability associated with the release and subsequent use of my medical records by authorized recipients.[br][/br][br][/br]
[b]Signature:[/b]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Date:[/b]
[size=85][i]DD/MMM/YYYY[/i][/size][br][/br]
[br][/br][/divbox][br][/br]
