Release Receive Form

* Required Information

Vera Okoye, DNP, CRNP, FNP-BC, PMHNP-BC

You First Health and Wellness Services LLC

50 West Edmonston Drive, Suite 208 Rockville, MD. 20852

Phone - 240-438-0325

CONSENT TO RELEASE/RECEIVE CONFIDENTIAL INFORMATION

I authorize at the above address to:

Patient Date of Birth *

Receive my medical history information from the following physicians:

Name

Address

Name

Address

Receive my treatment records from the following therapist:

Therapist Name

Therapist Address

Release my treatment information/records to the following healthcare professionals:

Name

Address

Name

Address

Release my treatment information to the health insurance company listed below for billing / authorization purposes.

Insurance Provider Name

Insurance Provider Address

This information is for the following purposes (any other use is prohibited).

I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken in reliance on it. This consent will last while I am being treated by the physician specified above unless I withdraw my consent during treatment. This consent will expire 5 years from date of signature.

I understand that the records to be released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illness. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient.

I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights.

Patient Name

Patient Signature *

Clear

Date

Parent/Guardian Name *

Parent/Guardian Signature *

Clear

Date

Witness Name *

Witness Signature *

Clear

Date

By checking this box, I consent to receive text messages related to conversations (external) from You First Health and Wellness Services LLC. You can reply "STOP" at any time to opt out. Message and data rates may apply. Message frequency may vary, text HELP to 240-438-0325 for assistance. For more information, please refer to our privacy policy, and SMS terms and conditions on our website.