Pure Release of Information Form

Pure Psychiatry Group

Authorization for Release/Exchange of Information Form
By signing this form I authorize Pure Psychiatry of Michigan PLLC, including all locations that Pure Psychiatry Group operates at, to release my medical records with specified party below.*

I authorize
Signing below grants permission to : Pure Psychiatric of Michigan PLLC
to release/exchange the following written and verbal information concerning: First Name* Last Name* . Date of Birth* with Name * at Location*. Street Address City State Zip and/or Email and/or Fax Number .
Information to be release: (including but not limited to)

Assessments: Initial Assessment, Diagnosis, Substance Abuse/Alcohol information, Behavioral, Medications, Therapy/Counseling Notes, Blood Work Results/Orders, Progress Notes, Treatment Concerns, Bariatric Concerns, Discuss finances with office staff.

Timing: This release will be valid until written notice to revoke this consent is provided to Pure Psychiatry Group by patient/guardian and signed by both parties. Persons or agencies receiving information may not further release it without the informed written consent of the client/guardian.
Client Full Name/Parent or Legal Guardian Full Name:*

First NameLast Name
Client Signature/ Parent or Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
Requesting Workers Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Pure Psychiatry Group