Authorization & Release Form

David B. Miller, Psy.D., P.A.

Diplomate, American Board of Professional Pyschology
Board Certified, American Board and Academy of Psychoanalysis
Practice of Clinical NeuroPsychology and Contemporary Psychoanalysis
Licensed Psychologist FL & CA
Boca Regional Hospital Physician #2076
5295 Town Center Road, Suite 401
Boca Raton, FL 33486
(561) 362-3739
www.drdavidbmiller.com

This form, when completed and signed by you, authorizes David B. Miller, Psy.D., P.A. to release & receive protected information from your clinical record to the person you designate.
Name
I authorize my psychologist, David B. Miller, Psy.D., and/or his administrator to release pertinent information. This information should only be released to:
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
As Dr Miller's patient you do not have to state the specific purpose for this request-it is simply a request by you as an individual with clinical information in this office.
Name of Previous Psychologist

I authorize my psychologist Listed below to release pertinent information from my clinical record to David B. Miller, Psy.D., PA
This authorization shall remain in effect until treatment is completed. You have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that my psychologist generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party.
Name of Patient
I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of your information and no longer protected by the HIPPA Privacy Rule.
Date*
E-Signature

Signature of Patient (or representative of the patient)
Relationship to Patient