Call us for an Appointment: 509 420 5060
Authorization ROI Form | NPP Integrative Psychiatry Clinic for Mental Health And Holistic Wellness Center Bellevue

Authorization ROI Form

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
Patient Name:
Date of Birth:
Patient Phone:
I, here by authorize of the RELIANCE HEALTH SYSTEMS to Obtain and/or Release my medical, psychiatric, alcohol, drugs, and / or HIV testing, ARC and AIDS diagnosis information contained in my records or disclose information

Obtain To:

NeuroPsych Program (Tri-Cities),1446 Spaulding Park Suite 303,Richland WA 99352, Phone: 509.420.5060, FAX: (509) 420-5059
NeuroPsych Program (Walla Walla), 128N 2nd Ave Suite 209, Walla Walla WA 99362, Phone: 509.525.1725, FAX: (509) 420-5059
Varad Program (Bellevue), Forest Office Park Building D Suite, 201, Bellevue WA 98007, Phone: 425.326.1662, Fax: 425 429 3751

Released From:

NeuroPsych Program (Tri-Cities),1446 Spaulding Park Suite 303,Richland WA 99352, Phone: 509.420.5060
NeuroPsych Program (Walla Walla), 128N 2nd Ave Suite 209, Walla Walla WA 99362, Phone: 509.525.1725
Varad Program (Bellevue), Forest Office Park Building D Suite, 201, Bellevue WA 98007, Phone: 425.326.1662
Name of Facility / Doctor:
Address of Facility / Doctor:
Facility / Doctor Phone:
Facility / Doctor Fax:
FOR THE PURPOSE OF:
Complete Record Progress Notes Only
Continuation of Treatment Coordination of Care Application for Insurance Legal Other (please specify)


I understand that my records are protected under Federal and/or Washington State Law and cannot be disclosed without my written consent unless otherwise provided for in the regulations (including 45 C.F.R Pts. 160 [HIPAA] and 42 C.F.R Part 2 [if I am receiving chemical dependency treatment services]). I also understand that my written consent is required to release any health care information relation to testing/diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, an alcohol or other drug use unless otherwise provided in the regulations. If I have been tested, diagnosed or treated for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, and/or alcohol or other drug use, you are specifically authorized to release all health care information relating to such diagnosis, testing, or treatments as indicated above. I understand that once the above information is disclosed, it may be re-disclosed by the recipient (except when prohibited) and the information may not be protected by federal privacy laws or regulations. I understand that I do not have to sign this authorization in order to receive health care benefits (treatment, payment, enrollment, or eligibility for benefits) except for health care services necessary to create any assessment or report for disclosure to the recipient identified in this authorization. *This authorization may be revoked at any time in writing, except to the extent that action has already been taken in reliance on it.


Patient / Legal Representative Signature

Provider / representative Signature