Release of Information

Submitter's Name

Submitter's Email

Under HIPAA regulations, Psych North cannot share protected health information with anyone unless the patient provides written consent. Many patients choose to involve trusted family members or support persons in their mental health care. This authorization allows Psych North clinicians to coordinate care, discuss treatment plans, share clinical updates, and communicate as needed with the individuals you designate.

You may revoke this authorization at any time in writing, except to the extent Psych North has already acted in reliance on your prior consent.

Individuals Authorized to Receive Information and Coordinate Care

I authorize Psych North to release my records and any requested information to the following individual(s), which may include family members, friends, advocates, case managers, ARMHS workers, or other support persons involved in my care(s):

Individual #1

Relationship to Patient #1

Individual #2

Relationship to Patient #2

Individual #3

Relationship to Patient #3

Individual #4

Relationship to Patient #4

Patient Information

Patient Name

Date

Signature

Clear