NEW PATIENT DEMOGRAPHIC INFORMATION
MEDICAL RECORDS RELEASE FORM
I authorize to release all my medical records from the below provided Date , including but not limited to, initial psychiatric evaluation, history and physical, progress notes ,procedure notes, medication history and lab reports
To Greater Heights Holistic Psychiatry from the following provider(s):
From Greater Heights Holistic Psychiatry to the following provider(s):
I understand that this form will be in effect for 1 year after termination of care from Greater Heights Holistic Psychiatry clinic. I understand that I can revoke this consent in writing at any time.