to download CSC Application Form - Child Study Center

AUTHORIZATION TO REQUEST HEALTH INFOMRATIONBE RELEASED TO CHILD STUDY CENTER(ALL INFORMATION MUST BE COMPLETED TO BE VALID)Patient’s Name _______________________________________________ Date of Birth ___________I authorize _______________________________________________ (current PCP, referring doctor or otherhealthcare provider) to release protected health information from the medical record of the above namedclient to:Child Study CenterAttn: CLIENT SERVICES1300 W. LancasterFort Worth, Texas 76102Phone Number: (817) 336-8611The specific purpose(s) for this disclosure is/are (check () your selection(s):( ) Sharing with other health care providers; ( ) Medication Management; ( ) Treatment Planning; ( ) Other (please describe):__________________________________________________________________________________________________________ I WANT / _____ I DO NOT WANT ( check one) the specified information to be released to include history, diagnosisand/or treatment for HIV testing, AIDS, communicable diseases, drugs/alcohol and mental health diseases if any.SPECIFY EXACT INFORMATION TO BE RELEASED: (1) Place a check () next to the specific information needed, (2) list thespecific dates of service. (3) List the clinician name.INFORMATION DATES OF SERVICE INFORMATION DATES OF SERVICEAdmission NoteDoctor’s Office RecordsHistory and PhysicalBirth RecordsSocial HistoryDischarge SummaryEducational TestingOutpatient Clinic NotesISD TestingPsychiatric EvaluationTeacher’s QuestionnaireLab and X-Ray ReportsVerbal CommunicationOther:_____ I understand that my records cannot be disclosed without my written authorization, except asotherwise provided by law._____ I also understand that I may revoke this authorization at any time except to the extent that actionhas been taken in reliance upon it._____ In any event this authorization will expire in 365 days from the date of my signature unlessotherwise specified by date, event or condition as follows:_________________________________________________________________________________._____ I understand that a photocopy or facsimile of this authorization is as valid as the original._____________________ ________________________________________________________ _____________________Date Signature of Patient, Parent, or Legal Guardian Relationship to Patient________________________________________________________Printed Name of Patient, Parent, or Legal GuardianChild Study Center Medical Records Department Phone: (817) 390-2990 Fax: (817) 390-2901 Revised 09-2012