REH/HRC Authorization Form
Transfer & Exchange of Health Information with HRC
Richard E Hicks, PhD
629 Oberlin Rd., Raleigh, NC 27605-1126, 919.961.1095
HRC Behavioral Health Psychiatry, PA
4201 Lake Boone Trail, Suite 201, Raleigh, NC 27607, 919.785.0384
Request/Authorization to Release Confidential Records and Information
I hereby authorize - Richard E Hicks, PhD to release information from records about ______, born on , ______for the following purpose(s):
Further mental health evaluation, treatment, or care Treatment planning Billing – both client and insurance billing
These records concern the time between first appointment and time of transfer of records (starting 07/01/13).
The information to be disclosed is marked by an X in the boxes below, and the items not to be released have a line
drawn through them.
Intake and discharge summaries _____ Medical history and evaluation(s) _____
Mental health evaluations _____ Developmental and/or social history _____
Educational records _____ Progress notes, and treatment or closing summary _____ Other: All records from Richard E Hicks, PhD
Please forward the records to the address HRC Behavioral Health and Psychiatry, PA.
HIV-related information and drug and alcohol information contained in these records will be released under this consent unless indicated here: Do not release.
NOTE: These records will become part of the records that Richard E Hicks, PhD maintains with his employment at HRC and thus part of the HRC records.
I have had explained to me and fully understand this request/authorization to release records and information, including the nature of the records, their contents, and the consequences and implications of their release. This request is entirely voluntary on my part.
______
Signature of client Printed name Date
______
Signature of parent/ guardian/representative Printed name (Relationship) Date
I witnessed that the person understood the nature of this request/authorization and freely gave his or her consent, but was physically unable to provide a signature.
______
Signature of witness Printed name Date
REH-HRC Authorization Form; Updated 07/02/2012 1 of 1