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David A. Baker, Psy.D., ABPP-CN (303) 704-1128 Pediatric Neuropsychologist [email protected] www.drdavidabaker.com
Authorization to Request and/or Release Confidential Information
Patient’s Name: _______________________________________________________________ Patient’s Date of Birth ______/_______/__________ Patient’s Social Security Number ______-______-_________ Name of Parent/Guardian _________________________________________________________________________ I hereby authorize David A. Baker, Psy.D., to (circle one or more) request, release or exchange information from, to, or with the following individual or institution: _______________________________________________________________________________________ Name of Individual, Provider or Institution ________________________________________________________________________________________ Address ____________________________________________ _________________________________________ Phone Fax
Specific information being requested, released, or exchanged:_______________________________________________ _________________________________________________________________________________________________ Options to include above: Medical records, lab results, imaging findings, treatment/progress notes, psychiatric records, verbal consultation between providers, psychological testing, educational testing, education plans, IQ tests and scores, school transcripts, college entrance exams, or complete school records including special education records. The purpose for the release of these records is for evaluation and treatment planning. This authorization extends to the release of any drug and alcohol related information in the record. This authorization may be revoked by notifying Dr. Baker in writing. A photocopy or facsimile transmission of this release shall be accepted as the original. Unless otherwise indicated here (expires _______________) This authorization expires 12 months from the date signed. Any information released by Dr. Baker to another individual or entity shall not be forwarded without written authorization and further consent by the patient or guardian. I understand that I have the right to receive a copy of this authorization upon my request. Signature of Patient or Legal Representative: ____________________________________________________ Date: ______________ Witness: _________________________________________________________________________________ Date: ______________