4396 Lawrenceville Road, Suite 101, Loganville, GA 30052
Office Number 678-830-2307 Fax Number 678-830-2511
CONSENT FORM
Consent To Release/Receive Confidential Information
I ,
Date of Birth:
authorize Total Care Behavioral Services, d/b/a Total Care Behavioral Services,
at the above address to:
Check All That Apply:
☐ Receive my medical history information the following physician / healthcare provider:
Fax Number:
☐ Release my treatment information/records to the following physician / healthcare provider:
Fax Number:
☐ Release my treatment information to the health insurance company / employer listed below for billing disability reporting purposes:
Fax Number:
Information To Be Released:
☐ Complete Record
☐ Progress Notes Only
☐ Labs
☐ Other
I understand that I may end this consent at any time, either verbally or in written form,
unless an action has been taken in dependent on it. This consent will expire 365 days
after I have completed my treatment, unless I notify the physician listed above otherwise.
I acknowledge that my records may include mental health care, substance use treatment,
and communicable disease information protected under 42 CFR Part 2.
