coordination-of-care

Insurance companies request that we coordinate care with your primary care provider and any other mental health professionals with whom you are working. While we ask all patients, the decision as to whether about communication occurs is yours. In the areas below please indicate whether you do, or do not, give permission for your Rock Landing Psychological Group clinician to communicate with your other provider(s). If you do give permission, please share their contact information with us on this form. Thank you for completing this form.

Name

Date

Rock Landing Psychological Group Provider

Patient DOB

Permission to release information about my treatment to my Primary Care Provider or other attending physician/provider.

I GIve Permission

I Do Not GIve Permission

Primary Care Provider Name

Phone

FAX

Permission to release information about my treatment to my Mental Health Care Provider.

I GIve Permission

I Do Not GIve Permission

Outside Mental Health Provider Name

Phone

FAX

Signature

Clear

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Coordination of Care with Primary Care Provider

coordination-of-care