Personal Growth

Better Quality of Life

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Authorization for release of confidential information (Primary Care Physician/Psychiatrist)

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  • I request and authorize _______________ (NAME of Therapist/Clinic) to release and receive my personal healthcare information between: (Enter NAME of Therapist/Clinic below)

  • CenterLife Offices

    Centerville Clinic 7039 20th Ave S, Centerville, MN 55038 Ph: 651-288-0332; Fax: 651-288-0493

    White Bear Lake Clinic 4444 Centerville Rd, Ste 235, White Bear Lake, MN 55127 Ph: 651-289-3111; Fax: 651-289-3113

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  • I understand the consent can be revoked at any time, except to the extent that disclosure made in good faith has already occurred in compliance of this consent. If revocation is not received, authorization will be considered valid for a period of one year from date the ROI was attained.

    The facility, its employees, officers, and attending physician are released from legal responsibility or liability for the release of the above information to the extent indicated and authorized.

    I understand that the information released could contain reference to Substance Abuse, Psychological, and/or Psychiatric Impairment.

    To the party receiving this information: this information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. FOR PATIENT RECORDS APPLICABLE UNDER FEDERAL LAW 42 CFS PART 2.

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  • Dear: _________________________________________________
    Our mutual client/patient has authorized us to be in communication to coordinate their care. Their Diagnostic Assessment was on __________________ and they will follow up with weekly/bi-weekly appointments and/or were referred to ________________________________________________________________
    Dx: ______________________________________________________________________________________________________________________________
    S/S: ______________________________________________________________________________________________________________________________
    Tx Goals: ______________________________________________________________________________________________________________________________
    Risk Factors/Special Concerns: ______________________________________________________________________________________________________________________________
    Clinician Signature: __________________________________________
    Date: ____________________
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