Raymond J.
Havlicek, PhD
Psychologist
Forensic &
Clinical Psychology
Diplomate in
Clinical Psychology
American
Board of Professional Psychology
Fellow,
American Academy of Clinical Psychology
220 South
Service Road, Suite 23
Roslyn
Heights, NY 11577
516-484-5388
516-776-9275
(fax)
&
30 Cayuga
Way
Lake Placid,
NY 12946
518-441-9426
516-776-9275
(fax)
CONSENT TO
OBTAIN
This form
when completed and signed by you, authorizes the release and exchange of
protected information from your clinical record to the person(s) you designate
RE:
_____________________, Parenting
Coordination or Court Ordered Forensic Evaluation (fill in name of
case)
Client/Patients’ Last Name: _____________________
Parties’
First Names: _____________________(Father);
_____________________ (Mother);
Additional
individuals:
_____________________________
DOB:________________
_____________________________ DOB:________________
_____________________________ DOB:________________
_____________________________ DOB:________________
Concerning
the medical/psychological/educational records of the above, I the undersigned,
hereby authorize Raymond J. Havlicek, PhD to (Check all that apply):
__ Obtain
information from
__ Phone contact only
__ Give
information to
__ Written material only
__
Obtain information and give information
__ Both by phone and in written form
CHECK
__
Information will be provided to Dr.
Havlicek by any individual Dr. Havlicek sends a copy of this release to.
Information will be provided to any individual or agency Dr. Havlicek
elects.
OR
__
Information will be provided to Dr.
Havlicek only by:
Name:
__________________________________________
Address:
________________________________________
*For
the purpose of furthering either the psychological evaluation of the above
client(s), or their Parenting Coordination, I understand that this authorization
is for the purpose of receiving and providing information. All diagnostic and
therapeutic information may be included with the following exception(s) (check
as appropriate):
__
No exceptions
__ Treatment
for drug and alcohol abuse
__ Specific
diagnostic information (specify):______________________________
__ Specific
treatment information (specify):______________________________
__ Other
(specify):_________________________________________________
**
I understand that information obtained pursuant to this authorization may be
subject to re-disclosure by the recipient of your information and as such is no
longer protected by HIPAA Privacy.
*** I
understand that this release will remain in effect until this case has been
settled, closed or decided.
Date:_____________Signed______________________________________________
Date:_____________Signed______________________________________________
Date:_____________Signed______________________________________________
Dr. Raymond
Havlicek
Witness
If you
downloaded this form please fill it out, and sign it, and fax it to:
516-776-9275, attention Dr. Havlicek