Behavioral Health Providers Physician Consent Form

Please fill out as much of the following Behavioral Health Providers Physician Consent Form.

Behavioral Health Providers will only use the information you provide on the Physician Consent Form to inform and/or coordinate treatment with your primary care physician.

Click here for our privacy policy on data and healthcare information

PRIMARY CARE PHYSICIAN NOTIFICATION OF CLINICAL SERVICES AND CONSENT FOR THE RELEASE OF INFORMATION

Thank you for choosing Behavioral Health Providers.

Unfortunately, paperwork is a necessity in modern health care. Please fill out all of the following necessary fields on this form.

Pursuant to Illinois Law PL 86-1434, you are hereby informed that it is desirable that you confer with your primary physician, if you have one, about seeking and receiving mental health services.

Unless you waive such notification, Behavioral Health Providers, P.C. is required to notify your primary physician that you are seeking or receiving mental health services.

Primary Care Physician Contact Information

Primary Care Physician Name *

First

Middle

Last

Primary Care Physician Phone

Primary Care Physician Fax

Primary Care Physician Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient or Guardian Contact Information & Acknowledgement

Patient / Guardian Name *

First

Middle

Last

Patient / Guardian Email *

Patient / Guardian Signature *

Clear Signature

I understand that my records are protected under the Federal and specific State confidentiality laws and regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (e.g., the provision of treatment upon consent to disclose third party payers) and that this consent expires automatically as described below. Information to be released includes diagnosis, treatment procedures and details of my condition which help to coordinate treatment. I further acknowledge that the information to be released was fully explained to me and this consent is given of my own free will. This release is valid for 90 days after last contact and I may cancel it in writing at any time.

Today's date *

Patient or Guardian Wish to Not Share Information with Primary Care Physician

Do not inform my physician (check here and sign below if you do not want your or your child's information shared with your primary care physician)

I do NOT want my physician to be notified or informed of my treatment

Patient / Guardian Signature