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

تم تحديد وضع الرسم. يتطلب الرسم استخدام الماوس أو لوحة اللمس. لإمكانية الوصول إلى لوحة المفاتيح، حدد كتابة أو تحميل.

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.