Medical Release for Current Patients



This form, when completed and signed by you, authorizes me to release PROTECTED HEALTH INFORMATION from your clinical record to the person whom you designate.

I authorize my psychologist, Floyd Covey, Ph. D., and/or his administrative staff to release the following information: __________________________________________________________________________________________ __________________________________Psychological Information_____________________________________________

The above information is to be released to: ________________________________________________________________________________________________________________

This authorization shall remain in effect for one year from the date of the signature, or until this specific date: ______________________________.

At any time, you have the right to revoke this authorization, only in writing, by sending such a written notification to the following address: Floyd Covey, Ph. D., P.O. Box 69, and Collierville, TN 38027-0069.  However, your revocation will not be effective to the extent that Dr. Covey has taken action in reliance upon your authorization, or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule.

Name of Patient: _____________________________________________

Signature of Patient: __________________________________________

Name of Guardian, If Patient is a Minor: __________________________

Relationship of Guardian to Patient: ______________________________

Signature of Guardian: _________________________________________

Date of Signature: ___________________________

Comments are closed.