Your Name *

First Name

Last Name

Date of Birth *

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Your Phone # *

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I confirm my consent to communication between the office of Tracey Jones, M.D., P.C. and my current Therapist/ Therapy Provider for the sole purpose of evaluating the appropriateness of adding Medical Cannabis to my wellness plan. *

I confirm

Name of Therapist/ Therapy Provider *

First Name

Last Name

Therapist Phone # *

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I understand that such communication will involve discussion and exchange of my healthcare history and will include protected health information (PHI) *

I understand

The specific information to be released is: DSM Diagnosis (5AXIS), Treatment History, & Treatment Plans for the purposes of evaluating the appropriateness of adding Medical Cannabis to my wellness plan. *

I understand

Information is requested from the last 12 months. *

I understand

I understand that if my healthcare history includes information concerning abuse/misuse of substances (including alcohol), mental health diagnosis or treatment, or HIV diagnosis or treatment, then I am required to provide specific consent to realease such healthcare history. *

I understand

I understand that refusing the disclosure of my healthcare history could result in improper diagnosis, improper treatment, or have other negative consequences. *

I understand

I understand that I have the right to revoke this approval at any time by making a request in writing to Tracey Jones, M.D., P.C. Revoking this Release of Information will not affect any information released before prior to my revocation. Revoking my approval to release records could result in improper diagnosis, improper treatment, denial of insurance coverage, or have other negative consequences. *

If at any time you choose to revoke your information, we will ask that you complete an accompanying Revocation Form which can be requested from the Office Manager at frontdesk@psychphilly.com

I understand

I understand that I have the right to refuse to release some or all of my records. I understand that such refusals may result in improper diagnosis, improper treatments, denial of insurance coverage, or have other negative consequences. *

I understand

I understand that I have the right to dispute any of the requested information above. (See DISPUTES below) *

I understand

I understand that it is my right to request a copy of this form at any time. *

I understand

I understand that Tracey Jones, M.D., P.C. cannot control people or organizations receiving this information to prevent re-release of it without my approval. *

I understand

I understand that I have the right to review/look at my information prior to its release. I understand that my service provider (or an assigned associate) will help me review this information and answer any questions I may have prior to its release. (See REQUEST REVIEW below) *

I understand

I understand that if I choose to review my information prior to its release, it may slow down the processes of my treatment planning and medication prescribing. *

I understand

I understand that this Release of Information has an expiration date of 12/31 of the current year. *

ROI will need to be renewed annually based on a need-to-know basis.

I understand

Digital Signature *

By typing my name below, I hereby grant the use of this information for the reasons explained in this form.

First Name

Last Name

Digital Signature - Guardian

Please utitilze this field if you are filling this out on behalf of somebody else. (Please place the patient's name in the field above.) By typing my name below, I hereby grant the use of this information for the reasons explained in this form.

First Name

Last Name

Today's Date *

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