Dr. Gerald B Harris, II

Available Forms

Consent/Release Form Contract for Long-Term Controlled Substances Therapy for Chronic Pain and/or Dependence/Addiction Financial Policy Insurance Information New Patient - Registration New Patient - System Review Referral Form Weekly Blood Pressure Log Well-Woman Exam New Patient - Health History Questionnaire New patient - Alcohol Screening Test New patient - Depression Screening Pain Assessment New patient - Drug Abuse Screening Test (DAST) Therapy Progress Report Well Man Exam

Consent/Release Form

Dr. Gerald B. Harris, II 18301 N. 79th Ave, Suite G190 Glendale, AZ 85308 623.977.0700 / 877.221.8094 (Fax)

Patient Name

DOB

I authorize DR. GERALD B. HARRIS II at the above address to:

Receive my medical history information from the following physicians:

Name, Phone #

Receive my treatment records from the following therapist/mental health professional or facility:

Name, Phone #

Release my treatment information/records to the following healthcare professional (s)

Name, Phone #

Release my treatment information to the health insurance company listed below for billing purposes

Insurance (s)

Release my treatment information to the following person (s)

Name (s)

This information is for the following purposes (any other use is prohibited):

I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken in reliance on it. This consent will last while I am being treated for opioid dependence by the physician specified above unless I withdraw my consent during treatment. This consent will expire 365 days after I complete my treatment, unless the physician specified above otherwise notified by me. I understand that the records to be released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illness. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient. I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights.

Patient/Guardian Signature: _______________

Date:

Witness/Staff Signature: __________________

Date:

* Required field