List of Medications and Dosages you are currently taking:

I certify by checking the box above and printing my name below that the above information is correct to the best of my knowledge. I will not hold responsible Elite Mental Health or any staff member responsible for any errors or omissions that I may have made in the completion of this form.

I authorize Elite Mental Health Clinic to make the disclosure of the following information: dates of service, diagnosis, medications prescribed to my primary care physician:

Should it be necessary for the practitioners at Elite Mental Health Clinic to consult with one another regarding my care, I give permission for such.
This authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1966 (P.L. 104-191), 42 U.S.C. Section 132d, et Seq., and regulation promulgated there under, as amended from time to time (collectively referred to as HIPAA”). This authorization affects your rights in the privacy of your personal behavioral health information. Please read it carefully before signing. I understand that the information in my health record may include information relating to sexually transmitted disease acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. Elite Mental Health Clinic will not condition treatment on your providing authorization for the requested use or disclosure. You may refuse to sign this authorization. You have the right to revoke this authorization, in writing, at any time, except to the extent that Elite Mental Health Clinic has taken action in reliance on it. By signing this authorization, I acknowledge and agree that any information used or disclosed pursuant could be at risk of re-disclosure by the recipient and no longer protected under HIPAA.

This information has been disclosed to you from record protected by 42 CR Part 2. The Federal Rules prohibit you from making any further disclosure unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFT Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose.

Medical/ Psychiatric care and treatment at Elite Mental Health Clinic may be provided by Physicians, Advanced Registered Nurse Practitioners (ARNP), Licensed Clinical Social Workers (LCSW), Licensed Mental Health Counselors (LMHC), or other State of New Jersey recognized behavioral health practitioners. I hereby authorize Elite Mental Health Clinic to evaluate, diagnose, and render appropriate treatment to the patient designated below. I hereby give my consent for Elite Mental Health Clinic and their Business Associate’s (such as, but not limited to, medical billing company, EHR vendor, collection agency, automated appointment reminder vendor, dictation service, and electronic prescription vendor) to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). You can ask for a copy of the Notice of Privacy Practices provided by Elite Mental Health Clinic which describes such uses and disclosure in detail. I have the right to review the Notice of Privacy Practices prior to signing this consent. Elite Mental Health Clinic reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Privacy Officer at 795 Parkway Avenue, Unit 2, Ewing, NJ 08618. You can also pick up a copy in our office. With this consent, Elite Mental Health Clinic communicate to me in reference to any items that assist the practice in carrying out TPO, such as, but not limited to, appointment reminders, billing statements, insurance issues and any messages pertaining to my clinical care, including laboratory test results, among others by use of phone calls to my home, mobile or other alternative location and speak or leave a message; SMS/Text message, Email, and/or postal delivery. It is further understood that all information given by the patient or family member to a treating clinician is confidential and will not be released, except under special circumstances, without patient consent or consent of legal guardian as described in details in the Notice of Privacy Practices. You can authorize us to release information relating to your treatment to another person, provider or company by signing a Release of Information (ROI) form provided by our office.

By signing this form, I am consenting to allow Elite Mental Health Clinic to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Elite Mental Health Clinic may decline to provide treatment to me.

I understand and agree with all the preceding information unless otherwise indicated in writing. I agree and accept the terms of all these documents.