AUTHORIZATION FOR COMMUNICATING WITH PRIMARY CARE PHYSICIAN OR OTHER HEALTH CARE PROVIDER
This form, when completed and signed by you, authorizes this provider to communicate with your Primary Care Physician, Psychiatrist, or other Health Care Provider (HCP) in order to coordinate your care. In some cases, your insurance company may requires this communication. Communication with any other person requires a separate release.
I authorize Kathleen M. Andolina, RN, CS, PC, Psychiatric Clinical Nurse Specialist, Lic. #14582o to release information about my psychological and/or psychiatric treatment, services and other discretionary related information for the purpose of care coordination and to advance treatment recommendations.
This authorization will remain in effect until treatment ends or changes in a significant way. You have the right to revoke this authorization in writing at anytime by sending such written notification to my office address. However, your revocation, will not be effective to the extent that I have taken action in reliance on the authorization or if this authorization, was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.