Consent for Release

Consent for Release

CONSENT FOR RELEASE OF PSYCHOLOGICAL TESTING

Patient's Last name

First name

Patient's Date of Birth(Required)

A. I authorize PsychNW, PC to release a copy of my complete Psychological Assessment including psychometric testing and diagnostic impression to:(Required)

4. (Person, Agency, School, Physician, etc. Please provide Address,Phone &fax if possible)

A (if 2nd release required)

5. (Person, Agency, School, Physician, etc. Please provide Address,Phone &fax if possible)

B. I authorize :(Required)

6. Name of Physician or Facility

Phone(Required)

7. phone

Fax

8. fax

to release a copy of my medical and/or mental health records to: PsychNW, PC Please fax my requested records to 503-914-0315

Date of Records:

Please send records dated from:(Required)

9.date from

To:(Required)

10. date to

This authorization includes oral communication.

I have read and do understand the above consent for releasing information, and I do sign this authorization for release of information freely, voluntarily, and without coercion. I understand that my records are protected under federal and State confidentiality laws and regulations and cannot be Scott T. Alvord, PsyD Licensed Psychologist S. Hans Stoltzfus, PsyD Licensed Psychologist Sean Robertson, PsyD Psychologist Resident Andrew Knowles, PsyD Psychologist Resident PsychNW, PC PO Box 671 Donald OR 97020 psychnw@psychnw.com website: psychnw.com P: 503-877-0711 F: 503-914-0315 disclosed without my written consent unless otherwise provided for in the regulations and laws. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it; and that in any event this consent expires automatically 90 days from the date of my signature. I specifically give authorization to FAX or SECURE EMAIL my medical information. I understand that risk is involved in faxing and/or secure emailing records and confidentiality at the receiving end cannot always be guaranteed. All faxed and/or securely emailed information will contain a confidentiality statement and instructions for returning misdirected information

Initials(Required)

Initials

11. initials

Signature of Individual or Legal Representative:(Required)

Name

12. legal sig

Printed name:(Required)

Name

13. print name

Date(Required)

14. todays date

If a minor, representative signature:

Name

15. Rep signature

Signature of :

parent

guardian

authorized person, if applicable

16. guardian

Email for PDF delivery(Required)

You will receive a password protected PDF email attached to your entries.