615 East Princeton Street, Suite 300 Orlando, Florida 32803 Phone: 407-898-6005 Fax: 407-898-7722 WELCOME TO OUR PRACTICE Thank you for allowing us the opportunity to serve you and your family’s needs. The Center for Child Development provides comprehensive multidisciplinary care to children with developmental, behavioral, social and academic needs. We are committed to delivering preeminent personalized services for children, adolescents and their families. A thorough history and physical exam is done during the first visit and when indicated, testing is completed at the second visit. Our mission is to improve children’s lives by helping them to achieve their best potential. In order for us to provide the quality of care that you expect and deserve please take a moment to review the following important information in regards to your appointment request. Appointment Date:

Appointment Time:

Patient Advocate:

Patient Phone:

Insurance Carrier:

Policy Number:

Please bring the following information to the appointment: ! Picture ID ! Insurance Card ! Referral from your primary care physician or whomever referred you to our practice ! Co-Pay/Co-Insurance – as a courtesy we will bill your insurance company and collect your copayment or deductible on the day of your visit. ! Patient Information Forms – please complete the enclosed patient information forms which are needed to assist us in the evaluation of your child. They can be returned to us via fax at 407-898-7722 or mail to the address above. Your child’s appointment may be shorter if you have not completed all of your paperwork before your scheduled appointment time. ! Copies of previous medical records if available ! Copies of previous evaluations, school reports, report cards, IEPs, teachers' reports and/or standardized test results: Cognitive (IQ), Achievement, Adaptive, etc. ! Please bring the teachers’ Vanderbilt behavior form completed if your child is older than 4 years.

Revised October 2013

Helpful Information Arriving to the appointment: Please plan to arrive 20 minutes before your scheduled appointment to allow us the time to register your child appropriately, collect your co-pay and update any changes to your insurance information, address or other contact information. • Co-payments are collected at the time of service. • You may have questions to fill out at each visit. Appointments and Cancellations: All services are by appointment only. We understand emergency situation arise and you may need to reschedule or cancel an appointment. If you are unable to keep your scheduled appointment please call 407-898-6005, we request a 24-hour cancellation notice if you are not able to attend a scheduled appointment. • A $25.00 fee will automatically be charged if you cancel your follow-up appointment with less than a 24-hour notice or no-show to your follow-up appointment. • A $50.00 fee will automatically be charged if you cancel your testing appointment with less than a 24-hour notice or no-show to your testing appointment. • Your insurance company will not cover this charge. • After 3 missed or canceled appointments, you may be discharged from our care. Late Policy: • If you are going to be more than 10 minutes late for your scheduled appointment time, we request that you call our office at 407-898-6005. We will do everything possible to accommodate the delay schedule permitting, though there may be times where we cannot accommodate the delay due to previously scheduled patient appointments and we may need to reschedule or modify your appointment. We work diligently to stay on schedule and ask that you arrive 20 minutes prior to your scheduled appointment to allow time for any necessary paperwork. Prescription Refill: • The Center for Child Development will not be able to provide your child with medication refills if you child has not been seen at their regularly scheduled appointments. • We require 2 business days notice to process all prescription refills, it may take up to 72 hours before it is mailed out. • For non controlled substance refills, please ask your pharmacy to fax a refill request to our office at 407-898-7722. Provider Phone Calls: • Our staff will respond to all calls within 24 hours on business days, excluding holidays. • If you are in an emergency situation please call 911 or go directly to the nearest emergency room. Insurance and Billing: Our office will bill your insurance as a courtesy for all participating insurance plans. We advise our patients to check with their insurance provider prior to their appointment to ensure the visit will be covered. • Payment is expected when services are rendered. • Your co-payment or co-insurance is to be paid on the day of your visit. Copies of Records: In general, the confidentiality of all communications between a patient and a health care provider are protected by law. Consequently, records of the services provided to your child can only be released with your written permission and we will provide a release of information form for you to sign. • Please let us know if you would like a copy of your child’s medical records sent directly to you there is a fee of $1.00 per page. Payment is required prior to the release of records. • When records are sent to another provider for continuity of care we will send this at no charge. Letters: There is no charge for the original diagnosis letter. • There is a $25.00 charge for detailed letters or forms, i.e. FMLA

Revised October 2013

615 East Princeton Street, Suite 300 Orlando, Florida 32803 Phone: 407-898-6005 Fax: 407-898-7722

I

have received the FHMG Center for Child Development

“Welcome To Our Practice” packet. I have read the packet or have had it read to me. I understand the following information provided and it is my responsibility to supply, review and/or complete:



Patient Information Forms



Previous Evaluation Forms



Arriving to Appointments



No Show / Cancellation Fee



Late Policy



Prescription Refills



Provider/Emergency Calls



Insurance and Billing



Co-Payments / Co-Insurance



Medical Records Release



Letters

Patient Name

Date

Patient or Parent/Guardian Signature

Date

FHMG Center for Child Development Staff

Date

Revised October 2013

 Center  for  Child  Development   Intake  Questionnaire    

Childs  Name:         County  of  Residence:         Allergies:         Child’s  Primary  Care  Doctor:       Who  suggested  this  evaluation?         Primary  concerns?         PRESENTING  HISTORY    

 

 

DOB:    

 

Age:    

 

 

 

 

     

Phone  #:    

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name  of  person  completing  this  form:                 Describe  your  concerns  about  your  child?                                                                                                 Please  describe  your  child:                                                           What  treatment  options  are  you  considering?                                     If  medication  is  suggested  as  a  part  of  your  child’s  evaluation,  are  you  willing  to  consider  it?        !  YES    !  NO     BIRTH  HISTORY    

                     

 

Pregnancy:     !  Diabetes    !  Seizures    !  Hypertension    !  Preeclampsia     During  pregnancy,  any:      !  Tobacco  use      !  Alcohol  use    !  Prescription  drugs       Describe:               1   Rev  07/14    

 

 

   

Delivery:        

 !  Cesarean  section  OR      !  Vaginal  delivery       Was  birth  on  time?    !  YES    !  NO     #  of  weeks  early:      #  of  weeks  late:       Mother’s  age  at  time  of  delivery:      prenatal  care:      !  Yes      !  NO       Did  child  require  resuscitation:      !  Yes    !  NO    Birth  weight:         Other                     Neonatal:    

 

   

     

   

 

Did  child  stay  in  special  nursery  or  NICU?    !  Yes  !  NO     how  long?             Did  child  have:      !  Respiratory  distress    !  Feeding  problems    !  Hemorrhage    !  Seizure       !  Low  Muscle  Tone              !  Jaundice       Other                           Did  child  require:    !  Ventilator     !  CPAP    !  Oxygen  !  Tube  feeding    !  Phototherapy       Passed  newborn  hearing  screen:    !  Yes    !  No     Florida  newborn  screening  results:    !  Normal    !  Abnormal       Age  at  hospital  discharge:     months     weeks       days       PAST  MEDICAL  CARE    

Medical  care  that  your  child  is  currently  receiving  from  any  other  providers:     Doctor  Name   Specialty                 Is  your  child  currently  being  seen  by  a  psychiatrist?  !  YES    !  NO     Has  your  child  ever  been  evaluated  by  a  psychiatrist?  !  YES    !  NO     Has  your  child  ever  been  admitted  to  a  mental  health  facility?  !  YES    !  NO     Therapies:      !  speech    !  OT    !  PT             Receiving  therapy  at:    !  school    !  home       Prior  medical  diagnosis  that  your  child  has/had?                   Diet  history  (regular  for  age?):                     Immunizations  up  to  date?      !  Yes  !  NO            Which  are  delayed?       Why   __________     Any  hearing  or  vision  concerns?                   2    

  SURGICAL  HISTORY      

Previous  surgeries  or  hospitalizations?     MEDICATIONS    

 

 

 

 

 

   

Any  prior  medications?                   Any  current  medications?                 Has  your  child  ever  had:      !  EEG      !  Brain  MRI    !  genetic  testing    !  metabolic  testing       Were  any  of  the  results  abnormal?      !  YES  or  !  NO     Which  test/s?         DEVELOPMENTAL  HISTORY    

 

 

 

 

 

 

 

 

Infant:   Child  took  solids  well?  

!  Yes    !  No  

Child  babbled  at  6  months  (BaBaBaBa,  DaDaDa,  GuGuGu)?          !  Yes    !  No   Child  sat  independently  at    

 months,  child  pulled  to  stand  at    

Child  babbled  DaDa  specifically  for  father  at    

 months.  

                         months,  MaMa  for  mother  at      

 months.  

  Toddler:   Child  walked  at    

 

Child  used  two  word  phrases  at    

 months    

 months  

Has  toilet  training  been  attempted?         !  Yes    !  No   At  what  age  did  child?    

Write  in  age  below:  

Hold  up  head    

 

Roll  over    

                  Gross  motor  delay?  

!  Yes    !  No  

Sit  unsupported        

 

Fine  motor  issues?  

!  Yes    !  No  

Stand  alone      

 

Sensory  issues?  

!  Yes    !  No  

Walk      

 

All  milestones  on  time?  

!  Yes    !  No  

Talk  

 

 

Toilet  train    

Speech  /  Language  delay?  

 

 

Feed  him/herself      

   

Dress  him/herself      

                                                                                                                                                       

 

3    

 !  Yes    !  No  

EDUCATIONAL  HISTORY      

Current  School  or  Daycare:           County:             Grade:           Type  of  class:  !  Mainstream    !  ESE    !  ASD    !  EBD  !  Other:       Any  pull  out  or  resource  services:                     Has  your  child  ever  been  home  schooled:  !  Yes  or  !  NO  which  grade/s:               Has  your  child  ever  repeated  a  grade:    !  Yes  or  !  NO  which  grade/s:               Does  your  child  have  a:  !  RTI  !  504  !  IEP       What  are  the  components  of  the  IEP/504  plan?                   SCHOOL  HISTORY                                             Previous  School   Age(s) Grade   Class  Type   Academic  or  Behavioral  Concerns   (Regular,ESE,ASD,EBD)                        

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Services  at  School   How  Frequently?   How  long/sessions   Individual  or  Group   Speech  Therapy           Occupational  Therapy           Physical  Therapy           Social  Skills             SOCIAL  HISTORY       Are  your  child’s  parents:          Married          Single          Separated          Divorced     Date  of  divorce  or  separation:         /______/______         Lives  with:    !  mother    !  father    !  step  mother    !  step  father          50/50                other:_________________     Custody  Arrangements:                     Are  there  any  custodial  issues?                                              

4    

 

FAMILY  HISTORY      

MOTHER  

Natural/  Adoptive/  Guardian   (circle  one)  

FATHER  

Natural/  Adoptive/  Guardian   (circle  one)  

Name:  

 

 

Name:  

 

 

Age:  

 

 

Age:  

 

 

Occupation:  

 

Occupation:  

 

Employer:  

 

Employer:  

 

Education  Level:  

 

Education  Level:  

 

STEP  MOTHER  

 

STEP  FATHER  

 

Name:  

 

Name:  

 

Age  

 

Age  

 

Occupation  

 

Occupation  

 

Employer:  

 

Employer:  

 

Education  Level:  

 

Education  Level:  

 

    Siblings  Name(s)  

Age  

How   Related  

    Grade   Medical  problems  

Behavior  problems/   Academic  problems/   Developmental  problems  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

 

5    

Medical  Condition  

Mom  

Dad  

Sister  

Brother  

Mom’s   Mom  

Mom’s   Dad  

Dad’s   Mom  

Dad’s   Dad  

Heart  Disease  

!  

!  

!  

!  

!  

!  

!  

!  

Diabetes  

!  

!  

!  

!  

!  

!  

!  

!  

Hearing  Problems  (not   from  old  age)  

!  

!  

!  

!  

!  

!  

!  

!  

Stroke:  Hypertension  

!  

!  

!  

!  

!  

!  

!  

!  

Arrhythmias  or  prolonged   QT  syndrome  

!  

!  

!  

!  

!  

!  

!  

!  

Seizures  

!  

!  

!  

!  

!  

!  

!  

!  

Thyroid  

!  

!  

!  

!  

!  

!  

!  

!  

School  problems  

!  

!  

!  

!  

!  

!  

!  

!  

Developmental  Delay  

!  

!  

!  

!  

!  

!  

!  

!  

Learning  Disabilities  

!  

!  

!  

!  

!  

!  

!  

!  

ADHD/ADD  

!  

!  

!  

!  

!  

!  

!  

!  

Autistic  Spectrum   Disorder  

!  

!  

!  

!  

!  

!  

!  

!  

Mental  Retardation  

!  

!  

!  

!  

!  

!  

!  

!  

Depression  

!  

!  

!  

!  

!  

!  

!  

!  

Alcoholism  

!  

!  

!  

!  

!  

!  

!  

!  

Anxiety  

!  

!  

!  

!  

!  

!  

!  

!  

Bipolar/Mood  difficulties  

!  

!  

!  

!  

!  

!  

!  

!  

Suicide  

!  

!  

!  

!  

!  

!  

!  

!  

Other:_______________  

!  

!  

!  

!  

!  

!  

!  

!  

  Is  there  any  chance  the  natural  mother  and  natural  father  are  related  outside  marriage?  !  Yes    !  No     Additional  stressors  include:                                    

6    

   

  REVIEW  OF  SYSTEMS   SCHOOL   ! Reading  problems   ! Poor  concentration   ! Learning  problems   ! Underachievement   ! Boredom   ! Afraid  of  School   ! Cannot  follow  directions   ! Handwriting  difficulties     RELATIONSHIPS   ! Clinging   ! Demanding   ! Dislikes  mother   ! Dislikes  father   ! Jealous  of  brother/sister   ! Shy   ! Dislikes  self   ! Bossy   ! Ignores  others   ! Aggression  towards  family   ! Does  not  get  along  with   teachers   ! Difficulty  making  and   keeping  friends     EMOTIONS   ! Sad  or  depressed   ! Angry   ! Fearful   ! Withdrawn   ! Over-­‐anxious   ! Unhappy   ! Sullen   ! Cries  easily   ! Sensitive   ! Daydreams   ! Imagines  things   ! Bad  dreams  or  nightmares   ! Hallucinations   ! Loses  temper   ! Preoccupied   ! Humorless   ! Flat  affect  

  BEHAVIOR   ! Poor  sense  of  right  and   wrong   ! Fights   ! Cheats   ! Steals   ! Lies   ! Tantrums   ! Destructive   ! Skips  school   ! Mean  to  other  children   ! Sets  fires   ! Runs  away   ! Rages   ! Quarreling   ! Rebellious   ! Classroom  behavior   problem   ! Lacks  initiative   ! Accident  prone   ! Overactive   ! Lazy   ! Blames  others   ! Wanders  off   ! Unreliable   ! Irresponsible   ! Easily  frustrated   ! Unpredictable   ! Cruel  to  animals   ! Perseveration   ! Short  attention  span   ! Compulsive   ! Immature   ! Manipulates     DEVELOPMENT   ! Health  problems   ! Poor  coordination/   clumsiness   ! Speech  problems   ! Delayed  development   ! Physical  handicap                 7  

  HABITS   ! Bed-­‐wetting   ! Chewing  clothes   ! Mouthing  objects   ! Soiling   ! Eating  problems   ! Nail-­‐biting   ! Thumb  sucking   ! Hair  pulling   ! Tics,  twitching,  blinking   ! Head  banging   ! Rituals   ! Obsessive  cleanliness   ! Rocking   ! Headaches     MEDICAL   ! Excessive  weight  loss   ! Excessive  weight  gain   ! Staring  spells   ! Involuntary  movements   ! Vocal  tics   ! Motor  tics   ! Headaches   ! Hypotonia   ! Been  tested  for  glasses   ! Lazy  eye   ! History  of  allergies   ! Feeding  difficulties   ! Frequent  gagging/choking   ! Physical  complaints   ! Stuttering   ! Eating  non-­‐food  items   ! Heart  murmur   ! Heart  palpitations   ! Chronic  constipation   ! Birth  marks   ! Nightmares     ! Night  terrors   ! Sleep  walking/talking   ! Trouble  getting  to  sleep   ! Trouble  staying  asleep  

Consent  to  Release  of  Health  Care  Information   I  acknowledge  that  I  have  received  a  copy  of  the  Practice’s  Notice  of  Patient  Privacy  practices,  which  describes  the  permitted   uses  and  disclosures  of  my  health  care  information  related  to  my  care  by  the  Practice,  and  payment  of  my  charges  for  the   services  received  at  the  Practice.    I  specifically  authorize  the  uses  and  disclosures  of  my  health  care  information  described  in   the  Practice’s  Notice  of  Patient  Privacy  Practices.   I  consent  to  release  of  my  health  care  information,  including  but  not  limited  to  medical,  psychiatric,  substance  abuse  or  HIV   information,  for:  (1)  medical  purposes,  including  but  not  limited  to  treatment,  prescriptions,  and  other  care  coordination   purposes;  or  (2)  payment  purposes  to  third  parties  including  but  not  limited  to  federal  or  state  health  plans,  insurance   companies,  collection  agencies,  employers  or  other  organization  responsible  for  payment  of  my  charges  for  the  services   received  at  the  Practice,  EXCEPT:   !  

!  

   

   

   

   

   

None    

 

(Please  initial)  

   

     (Please  specify)  

 

I  consent  to  the  Practice  taking  and  reproducing  pictures  (regardless  of  medium  [e.g.  photograph,  film,  tape,  etc.])  of  me  in   connection  with  my  diagnosis,  care  and  treatment  (including  surgical  procedures)  for  use  in  association  with  treatment,   scientific  and  educational  purposes,  and/or  Practice  department  functions  (e.g.,  performance  improvements,  etc.).   THE  UNDERSIGNED  MAY  RECEIVE  A  COY  OF  THIS  RELEASE  UPON  REQUEST,  AND  CERTIFIES  THAT  HE  OR  SHE  HAS  READ   THIS  RELEASE  AND  HAS  BEEN  ABLE  TO  ASK  QUESTIONS.    

 

 

 

Printed  Name  of  Patient                 Patient’s  Signature  &  Date                 Printed  Name  of  Legal  Representative/Principal  Obligor             Relationship  to  Patient  (Self,  Legal  Representative,     Principal  Obligator,  General  Agent)    

 

 

 

Printed  Name  of  Witness  

   

    Witness’  Signature  &  Date  

       

 

 

 

 

 

 

 

          Legal  Representative/Principal  Obligor’s  Signature  &  Date           Printed  Name  of  Interpreter  [if  applicable]  

 

  IF  THE  PATIENT,  PRINCIPAL  OBLIGOR,  LEGAL  REPRESNTATIVE,  OR  GENERAL  AGENT  IS  ONLY  ABLE  TO  GIVE  VERBAL   CONSENT  AS  AN  EMPLOYEE  OF  THE  PRACTICE  I  HAVE  SIGNED  THIS  FORM  ON  BEHALF  OF  THE  PATIENT  TO   ACKNOWLEDGE  THE  VERBAL  CONSENT  BY  THE  PATIENT  OR  THE  PATIENT’S  PRINCIPAL  OBLIGOR,  LEGAL   REPRESENTATIVE,  OR  GENERAL  AGENT,  TO  THE  PROVISION  OF  TREATMENT  BY  THE  PRACTICE.                         Printed  Name  of  Patient                 Printed  Name  of  Individual  Providing  Verbal  Consent           Printed  Name  of  Hospital  Employee           Practice  Employees’  Signature  &  Date      

   

 

Reason  Verbal  Consent  Obtained  

 

        Relationship  to  Patient  (Self,  Principal  Obligor,  Legal   Representative  or  General  Agent  

 

   

   

    Printed  Name  of  Witness  

 

 

 

   

   

    Witness’  Signature  &  Date  

 

 

 

 

 

PK5510  Back  (09/11)  

 

COMMUNICATION   USE  AND   DISCLOSURE  AUTHORIZATION     Section  A:    Please  complete  the  following  information  for  all  requests  

 

1.

Today’s  date:    

 

 

 

 

 

 

 

 

2.

Patient  name:    

 

 

 

 

 

 

 

 

3.

Date  of  Birth:    

 

 

 

4.  Patient  #:    

 

 

 

 

 

 

 

 

 

 

 

 

5.          Address:    

 

I  hereby  request  the  following  regarding  the  use  of  my  PERSONAL  HEALTH  INFORMATION:   1. You  may  leave  the  following  messages  on  answering  machines:       ☐  Referral  Information          

☐  Prescription  refill  information  

   

☐  Test  results    

   

☐  Other:    

2.

3.

 

 

   

 

 

You  may  discuss  information  regarding  my  treatment  and  care  with  the  following  family  members  and/or   friends:                          

 

 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

You  may  contact  me  regarding  my  treatment  and  care  at  the  following  numbers:                  

 

 

   

 

 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

       Signature  of  Patient  or  Guardian    

 

       Signature  of  Staff  Person  and  Title  

 

                 Printed  Name  of  Staff  Person  and  Title        

 

 

                     

  Date  

 

     

     

   

 

PK5510  Back  (09/11)  

AUTHORIZATION  FOR  USE  AND/OR  DISCLOSURE  OF   PROTECTED  HEALTH  INFORMATION   (MEDICAL  RECORD)   PLEASE  COMPLETE  ALL  FIELDS     SECTION A: Must be completed for ALL Authorizations

By  signing  this  Authorization,  I  hereby  authorize  and  permit  the  use  and/or  disclosure  of  my  protected  health  information  (medical   record)  for  the  limited  purpose(s),  and  in  the  limited  manner,  described  in  this  form.  In  addition,  I  understand  that  this  Authorization   is  completely  voluntary  and  I  am  signing  it  under  my  own  free  will.   Patient  Name:    

 

 

 

 

Patient  #:    

 

 

 

Home  Address:    

 

 

 

 

Date  of  Birth:    

 

 

Persons/organization  providing  the  information:  (Complete  w/Address)      

Center  for  Child  Development,  615  E.  Princeton  Street,  Suite  300,  Orlando,  FL    32803  407-­‐898-­‐6005  fax  407-­‐898-­‐7722  

Persons/organizations  receiving  this  information:  (Complete  w/Address)  

  Specific  description  of  information  (including  date(s))  to  be  used  and/or  disclosed  about  me:           *  The  following  items  must  be  initialed  to  be  included  in  the  use  or  disclosure  of  other  health  information:       *HIV/AIDS  related  health  information  and/or  records.       *Mental  health  information  and/or  records.       *Genetic  testing  information  and/or  records.       *Drug/alcohol  diagnosis,  treatment  and/or  referral  information  (Federal  regulations  require  a  description  of  how  much  and         what  kind  of  information  is  to  be  disclosed.  Federal  law  prohibits  the  disclosure  of  such  information.)          

SECTION B: Must be completed only if FHMG has requested the Authorization 1. FHMG  must  complete  the  following:  

 

   

a.

What  is  the  purpose  of  the  use  or  disclosure?  (check  one)            At  the  patient’s  (or  the  patient’s  representative’s)  request  or  direction            For  marketing.            For  fundraising.              Other  (describe):      

b.

Will  the  FHMG  practice  requesting  the  Authorization,  receive  financial  or  in-­‐kind  compensation,  directly  or  indirectly,  in       exchange  for  using  or  disclosing  the  health  information  described  above?      Yes      No  

 

 

 

PK5510  Back  (09/11)  

2. The  patient  or  the  patient’s  representative  must  read  and  initial  the  following  statements:   a. I  understand  that  my  health  care  and  the  payment  for  my  health  care  will  NOT  be  affected  if                  Initial:        

  b.

I  DO  NOT  sign  this  form.   I  understand  that  I  may  see  and  copy  the  information  described  on  this  form  if  I  ask  for  it,  and  that      Initial:     I  get  a  copy  of  this  form  after  I  sign  it.    

   

    SECTION C : Must be completed for ALL Authorizations

The  patient  or  the  patient’s  representative  must  read  and  Initial  the  following  statements:   I  understand  that  this  Authorization  will  expire.  (Please  choose  1  of  the  3  options  listed    below):     a. No  expiration  (permitted  only  for  Authorizations  used  to  create  or  maintain  research                              Initial:     databases  or  repositories).       b. On          (DD/MM/YYYY)                                          Initial:       c.  When  the  following  event  occurs                                            Initial:                                                         Signature  of  Patient  or  Patient’s  Representative                                    Date                          (Form  MUST  be  completed  before  signing)   Print  Name  of  Patient’s  Representative:      

 

 

 

 

 

Relationship  to  the  Patient:    

 

   

   

     

Reason  Authorization  is  signed  by  the  Patient’s  Representative:  (Check  one)     Minor   Incompetent   Other  (Explain)      

 

 

 

 

 

 

 

 

    *  YOU  MAY  REFUSE  TO  SIGN  THIS  AUTHORIZATION   *lf  this  Authorization  form  authorizes  use  and/or  disclosure  of  psychotherapy  notes,  it  may  not  be   used  to  authorize  the  use  and/or  disclosure  of  any  other  protected  health  information.   A  separate  Authorization  form  is  needed  for  any  other  use  and/or  disclosure.  

   

 

 

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