CURRENTLY ACCEPTING NEW PATIENTS IN TEXAS, VIRGINIA, COLORADO AND MISSISSIPPI

Authorization Form Internal

This form, when completed and signed by you, authorizes the person you designate to release protected information from your clinical record to me.

I authorize the following person to release information to Deniece R. McAdory, FNP-C, PMHNP-BC:

Untitled

I authorize the release of the following information:

Untitled

I am requesting the above person to release this information for the following reasons:

(“At the request of the individual” is all that is required if you are my patient and you do not desire to state a specific purpose.)

This authorization shall remain in effect until (fill in expiration date) or until (fill in an event that relates to the individual or the purpose of the use or disclosure).

You have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that my psychiatrist generally may not condition psychiatric services upon my signing an authorization unless the psychiatric services are provided to me for the purpose of creating health information for a third party.

I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.

Signature of Patient (and Patient’s Parent/Legal Guardian if applicable)

Date
MM slash DD slash YYYY

If the authorization is signed by a personal representative of the patient, a description of such representative's authority to act for the patient must be provided.

Contact Us Free

512-843-5169

online support available

[email protected]

Office Address

6705 W. Hwy 290 Ste 607 Austin, TX 78735

At Prestigious Guidance Services, PLLC, we believe in a world where compassionate care meets the highest standards of psychiatric practice. Our team, led by seasoned professionals, is dedicated to offering evidence-based treatment in a supportive, nonjudgmental space. Guided by values of integrity, empathy, and respect, we’re not just your healthcare providers — we’re your partners in the journey toward mental wellness.

CURRENTLY ACCEPTING NEW PATIENTS IN TEXAS, VIRGINIA, COLORADO AND MISSISSIPPI

Contact Us Free

Online Support Available

Authorization Form Internal

Contact Us Free

online support available

Office Address

Quick Links

Our Services

Hours of Operation

Contact Us