Lifeline Psychiatry
(770) 458-0450
contact@gapsychiatry.com
2150 Peachford Rd. Suite K Atlanta, GA 30338
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HOME
ABOUT US
SERVICES
TMS Therapy
Inpatient Services
Outpatient Services
SPRAVATO (ESKETAMINE) / KETAMINE THERAPY
STAFF
PATIENTS
DIAGNOSES
MEDICATIONS
RESEARCH
Current Clinical Studies
PATIENT FORMS
Release of Information Form
Clinic Policies Form
HIPAA Form
Demographics Form
History Form
BLOGS
CONTACT
Book An Appointment
MAKE A PAYMENT
Release of Information
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Release of Information
Lifeline Psychiatry LLC
2150 Peachford Rd, Ste. K, Atlanta, GA 30338
Ph: (770)458-0450, Fax: (770)458-0470
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I authorize
Lifeline Psychiatry LLC or Suneel Katragadda, MD
to disclose or release personally identifiable health information to the person, provider, and/or organization listed below.
I authorize the
person, provider, and/or organization listed below
to release personally identifiable health information to
Lifeline Psychiatry LLC or Suneel Katragadda, MD.
Person/Provider:
*
Address
*
Street Address
Phone
*
Fax
*
Person/Provider:
*
Address
*
Street Address
Phone
*
Fax
*
Organization/Facility:
*
Address
*
Street Address
Phone
*
Fax
*
Purpose of Disclosure: For receiving services or continuation of care at GA Psychiatric Services, LLC
Other
*
MEDICAL INFORMATION AUTHORIZED FOR RELEASE (CHECK ONES THAT APPLY)
Psychiatric Evaluation
In-patient Psychiatric Records
Therapy Notes
Medication List
HIV testing / treatment records
Drug / Alcohol Abuse Records
Psychological Evaluation
Out-patient Psychiatric Progress Notes
Discharge Summaries
Laboratory Results
Face Sheet or Demographics
Phone or Personal Communication
EXPIRATION
This authorization is valid from
*
to
*
I understand that this authorization expires in 180 days from the date of release if not noted above. I further understand that I may revoke this authorization anytime by written request and revocation becomes effective only from the date revocation is received.
PATIENT INFORMATION
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*
Date of Birth
*
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(IF PATIENT IS A MINOR)
Parent/Legal Guardian/Representative Name:
*
Relationship to Patient:
*
Signature
*
Date
MM slash DD slash YYYY
Witness Name:
*
Signature
*
Title:
*
Date
*
MM slash DD slash YYYY
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