Medical Authorization Consent: PREFERRED BEHAVIORAL HEALTH 141 Market Place Drive, Suite 100 • Fairview Heights, Illinois 62208 • Phone: 618-398-4226 MEDICAL AUTHORIZATION RELEASE FORM By signing and submitting this online form, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. *Yes, I understand and agreeNo, I do not understand or agreeName *Date of Birth *Street Address *Apartment, suite, etcCityStateZIP / Postal CodePhone *Consent: I authorize Preferred Behavioral Health to obtain or disclose information from my mental health record, which may include information about psychiatric diagnosis and treatment and substance abuse issues from or to: *Yes, I understand and agreeNo, I do not understand or agreeRequest Records From or Send To (Name): *Request Records From or Send To (Address):Apartment, suite, etcCityState/ProvinceZIP / Postal CodeRequest Records From or Send To (Phone#):Medical Records to be Disclosed/Obtained for these Dates of Treatment:Consent: *I understand that I may revoke this authorization at any time by notifying Preferred Behavioral Health at the address indicated above, in writing, and this authorization will cease to be effective on the date notified except to the extent action has already been taken in reliance upon it. *I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected by Federal privacy regulations. However, other state or federal law may prohibit the recipient from disclosing specially protected information, such as substance abuse treatment information and mental health information. *I understand that my refusal to sign this Authorization will not jeopardize my right to obtain present or future treatment for psychiatric disabilities except where disclosure of the information is necessary for the treatment. *My health care and payment for my health care at Preferred Behavioral Health will not be affected if I do not sign this form. *I understand that I can request a copy of this form after I sign it. *Yes, I understand and agreeNo, I do not understand or agreeConsent: I HAVE READ, UNDERSTAND AND AGREE WITH THE ABOVE STATEMENTS OF THIS AUTHORIZATION. *Yes, I agree and understandNo, I do not agree or understandConsent: Electronic Signature Agreement: By signing and submitting this online form, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Preferred Behavioral Health. Yes, I agree and understandNo, I do not agree or understandElectronic Signature (Type Full Name--Parent Guardian For Minor): *E-Signature Date *E-Signature Time *Hours-120102030405060708091011Minutes-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPM Submit Online FormPlease do not fill in this field.
