Ketamine Infusions for Depression & Pain • Free Consultations for New Patients • 850-906-5049

PATIENT PORTAL

KETAMINE PATIENT MEDICAL RELEASE FORM

Please complete the following forms to allow us to schedule your assessment

MEDICAL HISTORY QUESTIONNAIRE

RELEASE OF INFORMATION

Medical Release form

1. PATIENT INFORMATION- I authorize the release of medical information.

Name(Required)

First Middle Last

Email(Required)

Phone(Required)

Date of Birth(Required)

Last 4 of SSN(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

2. AUTHORIZATION FOR RELEASE. I understand that New Horizon Infusion Ketamine Clinic will not condition treatment, payment, enrollment or eligibility for benefits.

New Horizon Infusion Ketamine Clinic- Records Administration 1639-2 Village Square Blvd., Tallahassee, FL 32309 FAX: (850) 806-1862

Please select the correct option for the release of medical information

Request Health Information FROM Provider?(Required)

Please Select One

» Yes, Request Health Information FROM Provider

The person named above authorizes information to be requested or released by representatives of

Name of the Doctor or Facility(Required)

Name of Provider

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax Number

3. PURPOSE OF REQUEST. To obtain patient treatment history to determine appropriateness of ketamine infusion therapy.

Please select one(Required)

» Coordination of Care

4. RELEASE THE FOLLOWING INFORMATION

Please select all that apply(Required)

» Diagnosis

» Medications

»Treatment Plan(s)

» Discharge Summary

5. SPECIFIC AUTHORIZATION. I specifically authorize the release of ALL medical information relating to the above named patient including but not limited to the following categories protected by state or federal law:
(1) Substance abuse (drug or alcohol) treatment; (2) Mental health treatment; and (3) HIV-AIDS-related information, if such information is contained in the records. This authorization includes reports, clinical notes, correspondence, test results, and any other information in the records, whether generated by the authorized provider or another entity. The above provider/organization, its employees, representatives and any other person performing services for them or on their behalf, may need to obtain, use and disclose any and all information about physical and mental health, including but not limited to, services for preventative, diagnostic and therapeutic care, tests, counseling, and medical prescriptions. Confidentiality of this information is protected by federal law (HIPAA and 42 CFR Part 2). The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. 552a; and 38 U.S.C.5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary.

6. REDISCLOSURE. This release does not authorize re-disclosure of medical information beyond the limits of this consent.
The Recipient of this information is prohibited from using the information for other than the stated purpose, and from disclosing it to any other party without further authorization. I specifically understand and agree that the re-disclosure requirements set out above will apply to these records.

7. VALIDITY. I understand that this authorization will automatically expire one year from the date of my signature, and that I may revoke this authorization by sending a written notice to the person or entity authorized to make the disclosure described above.
I agree that any release which has been made prior to revocation and which was made in reliance upon this authorization shall not constitute a breach of my rights to confidentiality. You have the right to inspect the information you are authorizing to be re-released. The information you are authorizing to be released could be re-released or disclosed by the recipient. Such additional disclosures or releases may not be prohibited by law. We are not responsible for the actions of others who may be provided with information released as a result of this authorization.

I have read (or have had read to me) this authorization, and I agree to its terms as indicated by my signature below. I am entitled to a copy of this authorization.

Printed Name of Patient or Authorized Representative(Required)

Date

Comments

This field is for validation purposes and should be left unchanged.