Patient Name:__________________________________________

Communication between behavioral health providers and your primary care physician is important to help ensure 

that you receive comprehensive and quality health care.   This information will not be released without your consent.  

This information may include diagnosis, treatment plan, progress, and medication, if necessary.

I,______________________,       for the purpose of coordinating care, 

  (Patient’s name, printed)    

authorize Austin Psychiatric Alliance (APA), to release information related to my evaluation and treatment to:

PCP Name:________________________________  Phone: _______________

Address: __________________________________  Fax: _________________

_______________________________    _______________

(Patients signature)               (date)

Bottom sections to be completed by provider

The Patient was seen by me on ____________ (date) and was diagnosed with ________

The treatment plan recommended to the patient includes:__________________________

_______________________________________________________________________

 
For psychiatrist only: 
__ Medication was not indicated  ____ Patient refused medication ____ Psychotherapy only suggested 
__The following medications were started: _______________________________________________
                                                                      _______________________________________________
__ I recommended the following medical interventions by PCP before starting medications:
__________________________________________________________________________ 

Please call me at 512-637-9090 to discuss this case further or if you need any other information.

________________________                                     _____________________________

(Provider signature)                                                                               (Provider printed name)

Notice to recipient of this information:  This information has been disclosed to you from records which are protected by federal ( 42 CFR Part 2) and state laws regarding confidentiality.  

Such laws prohibit you from making any further disclosure of this information without specific written consent of the person to whom it pertains, or as otherwise permitted by law.  

A general authorization for the release of other information is not sufficient for this purpose.