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PA MH ROI #1

LifeBack
4 Princess Road Suite 206
Lawrenceville, New Jersey 08648
Phone 609-482-3701
Fax 609-482-3702
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
* I authorize LifeBack to    Select ONLY one - Release OR Obtain
Release information to:  
Obtain information from:  
* Name of person, facility, or agency
Address
* Phone #
Fax, email, other contact information
* I approve the following information to be released or obtained:
Patient's Presence/Participation in Treatment  Progress and Prognosis  Counseling Assessment 
Psychiatric Evaluation  Treatment Plan/Treatment Goals  Diagnosis 
Medication and Medical Information  Discharge Summary/Continuing Care Plan  Scheduling 
Medication Refills  Other 
* The purpose for this disclosure of information is to:
Coordinate care with other treatment provider(s)   Satisfy employment requirements  Satisfy legal requirements  
Satisfy school requirements   Coordinate with parent(s)/guardian(s)  Other 
  
* Expiration: Unless sooner revoked, this authorization is effective on the date signed below and expires on    NOTE: expiration date cannot exceed 365 days after today’s date.
* Signature
Signer Type:
Name:
Signature:
Sign with Touch
 
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