Coordination of Care with PCP
COORDINATION OF CARE WITH PRIMARY CARE PHYSICIANS
AND HEALTHCARE PROFESSIONALS
Patient Section to Complete
Patient Name:
Date of Birth:
MM
/
DD
/
YYYY
Patient Address:
Name of Patient’s Primary Care Physician
PCP’s Phone #
PCP’s Fax #
Signature *
Type your name here for your consent to use this information. "I authorize the disclosure of confidential mental health information between Pamela Hollings and my primary care / health care provider. I give permission for the disclosure of my diagnosis and treatment information for the purpose of continuity of care. I understand and expressly authorize the release of information related to substance abuse or HIV status. I undertstand that I may revoke this authorization, in writing, at any time."
Date:
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy