PCP / BEHAVIORAL HEALTH SPECIALIST
COORDINATION OF CARE FORM
I.
CONSENT for Release of Confidential Information to Primary Care Physician
PLEASE HAVE PATIENT COMPLETE.
CHECK ONE OR MORE OF THE FOLLOWING BOXES:
I,
, authorize my psychiatrist,
Patient Name
and/or my
Behavioral Health Professional Name
Behavioral health specialist,
, to communicate with my primary care
Psychiatrist Name
Physician,
, and to exchange/release the following confidential information:
Physician Name
[ ] The name and dosage of medications prescribed to me.
[ ] Recommendations for/or results of laboratory tests or diagnostic medical procedures.
[ ] The number of sessions attended, as well as the dates, frequency and type of care being provided.
[ ] The content and issues of my therapy including my diagnosis and estimated length of care.
[ ] HIV/AIDS information.
[ ] Alcohol or Substance Abuse information.
[ ] I, ___________________________, do not authorize any communication between my health practitioner
Patient Name
and my primary care physician.
The purpose of this information disclosure is to facilitate the coordination of my overall healthcare between my behavioral
health provider and my primary care physician.
This authorization is valid from the date signed for a period of one year. I understand I may revoke this authorization in
writing at any time, except to the extent of action already taken. Furthermore, I understand that I have a right to receive a
copy of this authorization.
Signature of Patient
Date
Signature of Legal Guardian
Date
Name of Patient (Please Print)
Witness
Copies:
Patient
Behavioral Health Professional
Patient Record
Notice to Recipient: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2) and/or state law. In accordance with
Federal and State law requirements, the information received pursuant to this document is confidential and recipient is prohibited from making further re-disclosure of this
information to any other person or entity, or to use it for any purpose other than as authorized herein, without the written consent of the person to whom it pertains or as otherwise
permitted by law. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information
to criminally investigate or prosecute any alcohol or drug patients.
BEHAVIORAL HEALTH PROFESSIONAL TO COMPLETE:
II.
CARE INFORMATION
In an effort to coordinate care, your patient, ______________________________________, has authorized
Patient Name
the exchange and release of the following confidential information:
[ ]
The name and dosage of medications prescribed:
The medications prescribed by
, includes:
Psychiatrist Name
Medication Name:
Dosage:
Start Date:
[ ]
Recommendations for/or results of laboratory studies or diagnostic medical procedures includes:
[ ] Lab Tests Indicated
[ ] Lab Tests Ordered
[ ] EKG
[ ] Other: Specify ____________________________________________
[ ]
The number of sessions attended, as well as the frequency and type of care being provided:
Care was initiated on
and sessions have been provided at frequency.
Date
The number of sessions attended is
Care is being provided at the following setting:
[ ] Outpatient
[ ] Inpatient
[ ]
[ ] Intensive Outpatient
[ ] Residential Treatment
[ ] Partial Hospital
[ ] Other: Specify
The content and issues of therapy including diagnosis and estimated length of treatment:
The diagnosis is:
The content and issues of therapy:
The estimated length of treatment is:
[ ]
HIV/AIDS information:
[ ]
Alcohol or Substance Abuse information:
Signature of Behavioral Health Professional
Copies:
Date
Patient
Primary Care Physician
Patient Record
Notice to Recipient: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2) and/or state law. In accordance with Federal and State law
requirements, the information received pursuant to this document is confidential and recipient is prohibited from making further re-disclosure of this information to any other person or entity, or to use it for any
purpose other than as authorized herein, without the written consent of the person to whom it pertains or as otherwise permitted by law. A general authorizat ion for the release of medical or other information is
NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug patients.