Health Information Request Form

Please fill out the following form in order to participate in our activity.

First name

Last name

Address

Email

Date of Birth

Please check records you are requesting

Progress note

Treatment Summaries

Intake Assessment

Medication Records

Other (please specify):

Purpose of Release:

Treatment

Insurance Purpose

Legal Reasons

Continuity of Care

Other (please specify)

Where to sent tis information

Self

Other please specify

Name

Address

Email

Phone

Relationship to client

This authorization is valid From

To

I understand that: The information disclosed may include sensitive and confidential medical records. I have the right to revoke this authorization at any time, except to the extent that action has been taken based on this authorization. The recipient may not re-disclose the information without my written consent, unless permitted by law.

I declare that the info I’ve provided is accurate & complete

Client Signature and date

Thanks for submitting!

Clinic Hours

Monday-Friday: 8am to 7pm

Saturday: 9am to 1pm

Sunday: Closed

We offer walk-in services from 5pm - 7pm to clients already established with a provider or clients who have completed a psychiatric intake but are struggling to wait for medication initiation/ management.

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Any Question Or Concern, Please Contact Us Here

First Name

Last Name

Email

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913-620-2990 or 913- 306-8688

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