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I hereby authorize Certus Psychiatry & Integrated Care to release medical information from the records of:

Patient Name*

I understand that the information released pursuant to this request will include health information related to psychiatric treatment, psychotherapy, HIV or AIDS-related conditions, communicable diseases, and treatment for drug and alcohol abuse, if any are applicable This authorization is for the release of all health information unless limited as follows:

I understand that my information is protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as amended. Regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records may also apply. I understand that unless revoked, this authorization is valid for the period of time needed to fulfill its purpose and up to three years, except for disclosures for financial transactions, wherein the authorization is valid indefinitely.

This information is to be disclosed to:
By signing below, I represent that I have read, understood, and consent to this disclosure.
Witness Name*
This field is for validation purposes and should be left unchanged.