Online patient form

Consent to Release of Information

Fields marked * are required. Your answers are sent securely to our intake team — nothing is stored in your browser.

First Name:

Last Name:

Date of Birth:

Patient Email

I hereby authorize the Center for Integrative Psychiatry to transfer, release, or obtain information with the individual(s) named below.

Name of Provider or the facility:

Mailing address:

Phone number:

Fax number:

I would like to make an exception of the following topics or areas of discussion. I do not give consent for information about the following to be discussed. — None

Patient Rights & Acknowledgment:
I understand that I may revoke this authorization at any time by submitting a written request, except to the extent that information has already been released.
I understand that signing this form is voluntary, and that my treatment, payment, or eligibility for benefits will not be affected if I choose not to sign.
I understand that once my information is released, it may no longer be protected under HIPAA if re-disclosed by the recipient.
I acknowledge that certain disclosures may be required by law, including but not limited to: court orders, subpoenas, law enforcement investigations, mandatory reporting of abuse or neglect, or when otherwise legally compelled.
I also understand that disclosures may occur to protect the safety of the patient or others, including situations involving risk of harm to self, threats to others, or public safety concerns.

Patient Full Name

Patient Date of Birth

Signer Full Name

PatientAuthorized Representative

Authorized Representative Full Name:

Relationship of the signer to Patient

SelfMotherFatherLegal Guardian

Patient Signature or Legally Authorized RepresentativeType your full legal name, then sign in the box below.

Sign here — draw with your mouse or finger

Draw your signature in the box above.

Date Signed:

Your submission is emailed securely to our intake team. This form is not for emergencies.