ROI - Well Minds Counseling

WELL MINDS COUNSELING, PLLC

Tana Carpita, MSW, LICSW

2525 E. Arizona Biltmore Circle, Suite B220

Phoenix, Arizona 85016
(425) 588.9280

Authorization for the Release or Exchange of Information

Patient Information

Client First & Last Name *

First

Last

DOB:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

This form, when completed and signed by you, authorizes Tana Carpita, LCSW to exchange protected health information (PHI) regarding you/your child with the following person(s) or organization:

Name of Individual/Organization:

Relation to Patient:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

For the purposes of: Care Coordination unless otherwise specified here:

This authorization includes disclosure of information in my chart regarding psychiatric consults and mental illness, developmental disabilities, alcohol or drug treatment, AIDS or AIDS-related illness, sexually transmitted infection, and/or HIV test results, unless I limit the disclosure to exclude the following:

Specific Information to be exchanged, obtained, or released:

Any Information requested, written or verbal, within reason to maintain client confidence
Behavioral/mental health documentation (assessments, measures, screenings, treatment plan, treatment summaries, NOT to include Progress Notes unless separately attached)
Psychiatric or Medical Information (medication reports, hospitalizations, medical conditions)
Other