Release of Information Form
I hereby authorize Nitin Bhosale, MD to share information with the entity/entities mentioned below.
I may cancel this authorization by checking “CANCEL” on this original form or by sending a written, signed and dated request to the doctor above indicating my desire to cancel. I understand that once my information has been released, the recipient might re-disclose it, my doctor has no control over it and privacy laws may no longer protect it. The purpose of this authorization is to improve the quality of my mental health evaluation or treatment.
Please be advised that certain information could be shared without patient's authorization in emergency situations to maintain safety of patient and others.
What is the purpose of this form?
By clicking this checkbox, I hereby authorize Nitin Bhosale, MD to share information with the entities mentioned below
By clicking this checkbox, I CANCEL any prior authorization given to Nitin Bhosale, MD to share information with the entities mentioned below
Name, Telephone, Fax and Address of the person/entity with whom your information will be shared
What information can be shared?
Mental health record (includes substance use information recorded as part of mental health evaluation and treatment)
Date of birth
Send me a copy of my responses.
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