Authorization To Treat

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Authorization To Treat

Occupational authorization for treatment

I authorize the named health care provider to release the information or records specified to The Doctors Treatment Center upon request in person or by mail to the address specified at the time of the request.
Patient First Name
Patient Last Name
DOB
Provider First Name
Provider Last Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Medication administration logs, dietary logs, staff contact or service logs, and other records that may not be part of my individual medical record, but which contain information relating to me. (These records should be redacted to protect information pertaining to other patients.)
- Yes
- Admission history and physical
- Discharge summary
- Complete hospital chart Office notes
- Outpatient records
- Psychiatric and other mental health records
- Records relating to drug or alcohol abuse (must specify the extent or nature of the records to be released)
- Lab Reports
- Radiological images
- Consultation notes or reports
- Complaints or grievances filed, with responses/dispositions
- Other (Specify):
Extent or nature of records to be released: (ex, specific hospitalization or visit):
- Investigating an allegation of abuse
- Providing advocacy services
- Other activities at the request of the individual
- Verifying my eligibility for services offered by the
- Legal Representation
This authorization will expire one year from the date of the signature below. I understand that I can revoke this authorization at any time by writing to the health care provider, but that revoking this authorization will not affect disclosures made or actions taken before the revocation is received.

I also understand that: I am not required to sign this authorization and that my health care or payment for care will not be affected by my refusal.

Federal privacy regulations will no longer apply to the information disclosed, and that may re-disclose the information.

I am entitled to receive a copy of this authorization. A copy of this authorization may be utilized with the same effectiveness as an original.
Patient or Representative Signature:
Date
Date Format: MM slash DD slash YYYY
Name of Representative (Print):
Relationship to Patient:
Locations:*
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240 East St, Plainville, CT 06062
7 Mill Pond Rd. Granby, CT 06035

(860) 747 - 4541 (860) 653 -2382

Drstreatment@gmail.com
Dtcgranby@gmail.com

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