Quiet Mind, LLC
Michelle Roberts, FNP, PMHNP
1722 NW Raleigh St.  Suite 211  Mailbox 410
Portland, OR 97209
Phone:  971 . 282 . 2346         Fax: 971 . 228 . 1382
quietmindportland@gmail.com

Request/Authorization to Release Confidential Records and Information 

Person, and / or Facility: ______________________________________________________________
Address: __________________________________   City: ______________   State: _______    Zip code: _________              
Phone: ____________________________________    Fax: _____________________________________________         Please cite your relationship to the Person or Facility listed (Primary Care Provider, Spouse, etc.): _______________
Other: ______________________________________________________________________________________

Identifying information about me, the patient: 
Name: ________________________________________________________________________________________
Address: _______________________________________________________________________________________
Phone: ______________________ Birthdate: ________________ Social Security #: __________________________
Guardian Name (if applicable): ________________________________   Phone of Guardian: ____________________

Please initial next to your request.
       _______ Inpatient or outpatient treatment records for physical and/or psychological, psychiatric, or emotional illness 
              or drug or alcohol abuse: 
		Date(s) of inpatient admission: _______________________________________________________________
		Date(s) of outpatient treatment: ______________________________________________________________
		Other identifying information about the service(s) rendered: _________________________________________
	_______ Psychological evaluation(s) or testing,		                    _______ Psychiatric evaluations, reports, or      	treatment records, and behavioral observations 				                 notes and summaries. 
	or checklists completed by any staff member or
	by the patient.
	_______  Treatment, recovery and aftercare plans.                          _______ Admission and discharge summaries. 
                   
      _______ Social histories, assessments with                                     _______ Close one’s subjective observation of    
			diagnoses, prognoses, recommendations, 				             patient's mental health wellbeing, both past    
			and all similar documents.								             and present.  
    																		
      _______ 	Academic, testing, achievement records.  																			
      _______ Teacher’s report, grades and observations.           	     _______ Information about how the patient's          	      					                                                                                       condition affects or has affected his or       
                                                                                                                                her ability to complete tasks, activities of
 																		      daily living, or ability to work.

______ Other: _____________________________________________________________________________________________
                      
HIV-related information and drug and alcohol information contained in these records will be released under this consent unless indicated here: ❑ Do not release HIV-related information  ❑ Do not release drug and alcohol information.

Select one, or both (Please write your initials In front of the option you select): 
______ Please forward the records to Quiet Mind, LLC at the address in the letterhead at the top of this form. 
______ Quiet Mind, LLC, please forward the records to the address I have provided above.
______ Allow Quiet Mind, LLC to speak with facility or person identified about my care.

I authorize the source named above to speak by telephone with the provider identified, about the reasons for my/the patient’s referral, any relevant history or diagnoses, and other similar information that can assist with my/the patient’s receiving treatment or being evaluated or referred elsewhere. 

I understand that no services will be denied me/the patient solely because I refuse to consent to this release of information, and that I am not in any way obligated to release these records. I do release them because I believe that they are necessary to assist in the development of the best possible treatment plan for me/the patient. The information  disclosed may be used in connection with my/the patient’s treatment. 

This request/authorization to release confidential information is being made in compliance with the terms of the Privacy Act of 1974 (Public Law 93-579) and the Freedom of Information Act of 1974 (Public Law 93-502); and pursu­ant to Federal Rule of Evidence 1158 (Inspection and Copying of Records upon Patient’s Written Authorization). This form is to serve as both a general authorization, and a special authorization to release information under the Drug Abuse Office and Treatment Act of 1972 (Public Law 92-255), the Comprehensive Alcohol Abuse and Alcoholism Pre­vention, Treatment and Rehabilitation Act Amendments of 1974 (Public Law 93-282), the Veterans Omnibus Health Care Act of 1976 (Public Law 94-581), and the Veterans Benefit and Services Act of 1988 (Public Law 100-322). It is also in compliance with 42 C.F.R. Part 2 (Public Law 93-282), which prohibits further disclosure without the express written consent of the person to whom it pertains, or as otherwise permitted by such regulations. It is in compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191.

In consideration of this consent, I hereby release the source of the records from any and all liability arising there from. 

This request/authorization is valid during the pendency of any claim or demand made by or in behalf of me/the patient, and arising out of an accident, injury, or occurrence to me/the patient. I understand that I may void this request/ authorization, except for action already taken, at any time by means of a written letter revoking the authorization and transfer of information, but that this revocation is not retroactive. If I do not void this request/authorization, it will automatically expire in 1 year from the date I signed it. 

I agree that a photocopy of this form is acceptable, but it must be individually signed by me, the releaser, and a witness if necessary. 
I have been informed of the risks to privacy and limitations on confidentiality of the use of electronic means of information transfer, and I accept these. I affirm that everything in this form that was not clear to me has been explained. I also understand that I have the right to receive a copy of this form upon my request. 

Signatures: 

____________________________________	______________________________	_______________________
Signature of client 									Printed name 								Date 

I, a mental health professional, have discussed the issues above with the patient and/or his or her parent or guardian. My observations of behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. 

____________________________________	_________________________________	____________________
Signature of professional 							Printed name 								Date 
________________________________________________________________________________
Complete this section only if applicable:
____________________________________	________________________	_______________	_____________
Signature of parent/guardian/representative 				Printed name 						Relationship 			Date 
			
I witnessed that the person understood the nature of this request/authorization and freely gave his or her consent, but was physically unable to provide a signature. 
	
____________________________________	______________________________	_______________________
Signature of witness 								Printed name 							Date