Rittenhouse Women's Wellness Center

Available Forms

A.) Internal Medicine Authorization to Release Healthcare Information A.) Internal Medicine Health History Form A.) Internal Medicine HIPAA : Notice of Privacy Practices A.) Patient Registration B.) Dermacenter Client Information and History C.) Nutrition 3 Day Food Diary C.) Nutrition History D.) Dr. Perilstein: Emotional Well-being Authorization to Release Protected Health Information D.) Dr. Perilstein: Emotional Wellbeing Consent for Treatment D.) Dr. Perilstein: Emotional Wellbeing Receipt of Privacy Information E.) Dr. Liggera's Patient Registration Form F.) Payment and Cancellation Policy G.) Email Agreement

D.) Dr. Perilstein: Emotional Well-being Authorization to Release Protected Health Information

Authorization to Release Protected Health Information

Name

Date of Birth

I request and authorize (physician and/or practice listed below) to release healthcare information of the patient named above to: Joanne Perilstein, Ph.D. at Rittenhouse Women's Wellness Center, 1632 Pine Street, Philadelphia, PA, 19103

Physician/Practice name, address, and phone/fax number

The undersigned has been informed that he/she has the right to revoke consent at any time by written request. This authorization is therefore subject to revocation at any time except to the extent that action has been taken in reliance on the authorization.

This authorization is valid beginning on

Date

And for a specified time ending on

Date

The undersigned has been informed of his/her right, subject to section 7100.113 of the Pennsylvania Mental Health Procedures Act, to inspect the material to be released.

This form has been clearly explained and I certify, by entering my name below, that I understand its contents

Enter name and date here to certify this statement and allow release of your records

* Required field