General Consent Form(Part-2) | Holistic

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Do you have a:

Primary Care Physician

Yes

No

Dentist

Yes

No

Request of Medical Records for:

Full Name

DOB OF PATIENT

Client’s Phone Number:

Client’s Email:

Name:

Birth Date:

Doctor’s Name:

Type of Doctor:

Practice Name:

Phone

Email

Fax

I, (Parent/guardian)

, authorize,

to release my last yearly physical examination to Holistic Elevation LLC . Information shall consist of: Duplicate records and/or verbal consultation concerning treatment and/or education.

Specifically:

Treatment plan/goals

Educational Evaluation

Summary of Psychiatric History

Diagnosis

Summary of Social/Family History

Discharge Summary

Other: Last documented physical assessment by primary care physician or nurse practitioner

__I CONSENT for my medical records to be released to Holistic Elevation

___ I DO NOT CONSENT for my medical records to be released to Holistic Elevation

OR

REFERRAL/RECOMMENDATION FOR PRIMARY CARE DOCTOR (PCP)

Client [ FULL NAME]

DOB OF PATIENT

Client’s Phone Number:

Client’s Email:

Due to lack of medical accessibility, discontinued medical treatment, untreated medical condition and/or not having a primary care doctor. I was recommended to gain access to a primary care doctor (PCP).

___ I ACCEPT the recommendation that was made to explore medical professional accessibility for my care.

__I DO NOT accept the recommendation that was made to explore medical professional accessibility for care.

Signature of Client

Le mode de dessin a été sélectionné. Le dessin nécessite une souris ou un pavé tactile. Pour l'accessibilité du clavier, sélectionnez « Saisir » ou « Importer ».

Printed name of Client

Date picker

*This consent is valid until client discharge.

The physical examination copy can be emailed to intake@holisticelevation.org or faxed to 302-278-0047.

If you have any questions or concerns contact Holistic Elevation LLC at 302-278-0026.