Your Family Clinic LLC

514 Old Richton Rd.

Petal, Mississippi 39465

601-544-8935

Billing Address

67 Mars Hill Road

Petal, MS 39465

AUTHORITY TO RELEASE OR OBTAIN INFORMATION

I (print name)______hereby consent to:

  The exchange of information between:

Your Family Clinic LLC / Dan Moore

(name of agency/individual releasing information):

And:

(name of agency/individual receiving information):

For the specific purpose of coordination of services and ongoing treatment.

  The release of any and all information pertaining to my treatment from:

(name of agency/individual releasing information):

To:

(name of agency/individual receiving information):

I specifically consent to release/obtain medical records and/or mental health information pertaining to:

  Evaluations /   Substance Abuse Records /   Identifying Information
  Case Notes /   Diagnosis /   Summary of Contacts
  Psychiatric Records /   Prognosis and Recommendations /   Treatment Planning
  Other______

I understand that I may revoke this consent at any time except to the extent that the action has been taken thereon. I further understand that this consent will expire (please check one):

____ when I am no longer receiving services from Dr. Dan Moore or my case has been closed.

____ on the following date ___/___/_____.

______

Signature of Client or Legal Guardian Date

______

Signature of Witness Date

Note to Program Receiving This Information:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of this person to whom it pertains or otherwise permitted by 42 CFR part 2. A general Authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.