Authorization for use and disclosure of protected information

Name of patient: ________________________________________________ Date of birth: ________________,

If patient is a minor (under age 18), this form must be completed and signed by parent or legal guardian. Enter name of person completing this form and relationship to patient if that is the case:

Name of parent/guardian: ________________________________________________ Relationship: ________________

__________________________________________________________________________________________________

Address of patient/family:

______________________________________________________

Phone:

___________________________________________

In signing below I authorize the following treatment facility:

Name of treatment facility or clinician _______________________________ ______________

Address: ______________________________________________________________

City _______________________ State ________ Phone __________________

To release the following information (check all that apply)________________________________________________

□ Psychiatric Records

□ Psychological Testing

□ Substance abuse treatment

□ Records of Psychiatric Hospitalization

□ Medical Records

□ Diagnostic & Laboratory Testing

□ Conversation between clinicians

□ Conversation with family/friend

□ Other:____________________

Regarding services rendered during the following dates: _______________

To: Dr. Valentine Raiteri, M.D.: 5 W. 19^th Street, 9^th Floor; New York, NY 10011

The purpose of this disclosure is for treatment and continuity of care.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the treatment facility or clinician named above. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurance with the right to contest a claim under my policy.

I understand that this authorization for disclosure is voluntary and that I need not sign this form to ensure healthcare treatment.

This authorization will expire on ______________________ (if no date is entered it will expire in 12 months from the date signed).

Signature of patient, or of parent/legal guardian if patient is a minor:

Signed: _________________________________ Print Name: ________________________ Date __________

Signature of Witness ____________________________ Print Name: ________________________ Date __________