California Clinic for Anxiety Disorders, P.S Annie Zadori, PsyD License number: PSY32733 Patient Name: First AUTHORIZATION TO RELEASE INFORMATION TO FAMILY MEMBER OR OTHER MEDICAL PROVIDERMany of our patients allow family members such as spouses, children, or others to call and request the results of tests, procedures, or other concerning issues. Under the requirements for HIPAA, we are not allowed to provide these information to anyone without the consent of the patient. If you wish to have your test and/or concerning issue information released to a family member or other medical professional you must sign this form. Signing this form will only give consent to release appointment information, test and/or concerning issues to family members named below. This consent form will not allow any further information to be released to family members. You have the right to revoke this consent in writing. I authorize Annie Zadori, Psy.D or her Registered Psychological Assistant to release information regarding appointments, tests, and concerning issues to the following individuals:1. Name & phone number: Relationship to Patient: 2. Name & phone number: Relationship to Patient: 3. Name & phone number: Relationship to Patient: This consent form will be in effect as long as I remain a patient of Annie Zadori, Psy.D.PATIENT or PARENT/SPOUSE SIGNATURE:Date: MM slash DD slash YYYY CONFIDENTIALITY NOTICEThe documents including and/or accompanying this telecopy transmission contain confidential information belonging to the sender that is legally privileged. This information is intended only for the use of individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy the information after its stated need has been fulfilled, unless otherwise required by state law. If you are not the intended recipient you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange for return of these documents.
