Consent to exchange of information

CLIENT/PATIENT INFORMATION

Today's Date *

Title *

First Name *

Last Name *

Gender *

Date Of Birth *

Email Address *

Contact number to be reached by Clinician? *

Alternative Phone Number (If phone line is disconnected or unavailable) *

CONSENT TO EXCHANGE OF INFORMATION

Note: Ensure a separate consent to exchange information is sent to each third party

CONSENT TO EXCHANGE OF INFORMATION

Privacy and Your personal Health information

The privacy of your personal information is important to us and is protected by law and governed by internal policies. You have a right to access and share your Health information following submission of this signed consent.

I (Full Name) *

Of *

Hereby consent to and authorize Monarch Mental Health Group to exchange clinical records and information which includes (Place an X in each box that you consent to be released):

Complete clinical file
Letters, referrals, and correspondence
Part of my clinical file (Please specify):

Specific Documents/Details

To the specified Health Provider/Person below

Name Of Institute *

Name Of Medical Practitioner/Person *

SIGNED CONSENT

Client Name/ Legal Guardian *

Date *

Patient/ Guardian Signature *

Draw signature|Type signatureClear

A copy of the authorisation shall be deemed as orignial and valid for a period of three months from the date completed