Release Forms
REQUEST FOR CONFIDENTIAL INFORMATION
TO: __________________________
______________________________
______________________________
I, the undersigned, have contacted the OCD Recovery Center
to arrange for treatment in their Intensive Outpatient___, IOP___,
or Retreat___ programs. Their office would like to contact you in order to
obtain information about my or my child's current psychological or
physical health. For this purpose and for the purpose of continuing dialog
between your respective offices I grant you full and unlimited permission
to release any information contained your treatment records pertaining to
the below named patient/individual who is either myself, or a minor under
my custody. Please forward this information to or otherwise contact at
your earliest convenience:
Christian R. Komor, Psy.D.
OCD Recovery Center
3501 Lake Eastbrook Blvd, Suite 250
Grand Rapids, MI 49546
Signed:
___________________________________ |
Date:
___________________________________ |
Name:
___________________________________ |
D.O.B.:
___________________________________ |
Address:
___________________________________
___________________________________
___________________________________ |
Relationship to Above:
___________________________________ |
Witnessed:
___________________________________ |
Date:
___________________________________ |
PERMISSION FOR OCD Recovery Center
TO RELEASE INFORMATION
I, ____________________________________ Date of Birth
________________________
(patient name)
Authorize
______________________________________
to release information in my health records to the individual or agency
listed below:
____________________________________________________________________
(Name of individual or agency)
____________________________________________________________________
Specify information to be disclosed:
____________________________________________________________________
The Purpose of the disclosure is:
___________________________________________________________________
- I understand that my records are protected under Federal and State
law and cannot be disclosed without my written consent unless otherwise
provided by law. I further understand that specific type of information
to be disclosed may, if applicable, include: Diagnosis, Prognosis,
treatment for Physical, Mental and/or Emotional illness, including
treatment of Psychiatric, Substance Abuse, HIV/AIDS for any admissions.
- I understand I have the right to revoke this authorization at any
time unless the facility which is to make the disclosure has already
done so in reliance upon my previous authorization. This authorization
may be revoked by submitting a written, dated notice of revocation to
the facility releasing this information. If not revoked, the release is
valid until it expires 6 months from the date signed below or until the
following date, event or condition:
_______________________________________________________________.
- I hereby release Christian R. Komor, his employees, staff and agents
from all legal responsibility or liability that may arise from
disclosure of the information set forth above relating to my file.
| Patient Signature:
___________________________________ |
Date:
___________________________________ |
| Parent or Legal Guardian Signature
___________________________________ |
|
Witnessed:
___________________________________ |
Date:
___________________________________ |
Further release of information disclosed by the above authorization is
prohibited by the Michigan Mental Health Code (Public Act 258 or 1974 as
amended, section 749 (3). The released information may not be copied,
shared, or re-released, except as is in compliance with Title 42 of the
Code of Federal Regulations Part II, which also prohibits disclosure.
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