PATH Release of Information - Touchstone Mental Health

Client Name*

First Last

Chosen Name

First Last

Date of Birth*

Previous Name(s)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Consent to Request and/or Release: I authorize Touchstone Mental Health to (check that apply):*

Request and use the following protect health information from the provider(s) below
Release the following information to the provider(s) below

My consent about allows Touchstone to use and/or request the following types of information:*

Specific dates/years of treatment (optional)

Other special instructions/limitations

Special Consent: The following information requires special consent by law. Even if you indicate all health information above, you must specifically authorize the following information in order for it to be requested or release:*

Chemical dependency program (see definition in instructions)
Psychotherapy notes (this consent cannot be combined with any others; see instructions)

My consent above applies to the following individuals/provider(s):*

Please provide the name of the provider, primary contact, address, phone number, and fax number for each provider listed.

My consent above applies to the following individuals/provider(s):

Please provide the name of the provider, primary contact, address, phone number, and fax number for each provider listed.

Contact Information for the person completing this form:*

First Last

Daytime Phone*

Program

Email*

Reason(s) for Request or Release: by authorizing the release of records, you are giving permission for written information to be released and used by Touchstone Mental Health and its staff person or provider specified above your health information. Reason(s) for releasing/requesting information:*

Coordination of Care
Payment
Emergency Only
Other (please explain)

If you picked other above, please explain here

I understand that by signing this form, I am requesting that the health information specified above be either sent or received. I may stop this consent at any time by writing to the organization(s), facility and/or professional(s) named above. Any request to revoke release is applicate from that date forward. I understand that when the health information specified above is sent to the third party, the information could be re-disclosed by the third party that receives it and may no longer be protected by federal or state privacy laws. I understand that if the organization named above is a health care provider, they will not condition treatment, payment, enrollment or eligibility for benefits whether I sign the consent form.*

I hereby authorize the release of the request information as indicated above.

This consent will end one year from the date the form is signed unless I indicate an earlier date or event here:

Release Expiration Date
Specific Event

If you answered the above question, please provide more details here:

Name*

First Last

By typing my name below, I acknowledge that this electronic signature has the same effects as my handwritten signature.*

I agree to the use of my typed name as my offical signature on this document.

Date*

Was a personal representative present?*

Yes
No

If yes, please provide more information:

First Last

Date

Description of personal represnetative's authority:

Name

First Last

For the personal representative: by typing my name above, I acknowledge that this electronic signature has the same effects as my handwritten signature.

I agree to the use of my typed name as my offical signature on this document.

Phone

This field is for validation purposes and should be left unchanged.