Authorize Release of Information
Need Palm Beach Psychiatry to send your records to someone—or obtain records from someone involved in your care?
A signed authorization allows us to appropriately release or request your health information.
Who should I list on the authorization?
This depends on where you want the information to go or where the information needs to come from. If you want records sent to another person or organization:
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Identify the person or organization that should receive the records.
Examples may include:
Another physician or healthcare provider
Therapist or psychologist
Hospital or treatment facility
School or university
Attorney
Another organization
Another person you specifically authorize
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Identify the physician, practice, hospital, facility, or organization that currently has the records.
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Indicate that you, the patient, are the intended recipient and provide the requested delivery information.
Please complete the authorization carefully
The form should clearly identify:
🔹 Who is authorized to release the information
🔹 Who is authorized to receive the information
🔹 What information may be released
🔹 The purpose of the disclosure, when applicable
Please sign and date the authorization before submitting it.