Medical Release Form
By filling out the form below, the named person voluntarily gives consent to an authorize my health care provider RVA Psychiatry and Wellness, specifically Robert "Trip" Young, NP to use or disclose my health information during the term of this Authorization to the recipient(s) that I have identified below.
Email address *
Patients Full Legal Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Patient's Full Address *
Your answer
Patient's Phone Number *
Your answer
I Authorize my Healthcare Information to be Released to (Family Member, Therapist, or Health Care Entity's Full Name) *
Your answer
If Under 18yrs Old Please List Parents Full Name Below *
Your answer
Health Care Entity / Therapist Full Address *
Your answer
Health Care Entity / Therapist Phone & Fax Number *
Your answer
Information To Be Release *
Required
Information To Be Release (If Specific Only) *
Your answer
Duration Of Release *
Required
Duration Of Release (If Specific Dates Only) *
Your answer
Writing your full name below signifies that you understand this form authorizes RVA Psychiatry and Wellness, LLC to release and/or exchange medical information with the above named Health Care Entity / Individual. If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation to the RVA Psychiatry and Wellness, LLC. The revocation will be effective immediately upon my health care provider’s receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation. *
Your answer
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