In Case of Emergency

Authorization to Release Health Care Information IN CASE OF EMERGENCY

First Name(Required)

Last Name(Required)

Date of Birth(Required)

West County Psychological Associates has my permission to contact the following person in case of emergency:

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

WCPA will only exchange information pertinent to the emergency.

This authorization ends:(Required)

on this date:

or when the following occurs:

Date(Required)

Please explain(Required)

I may cancel this authorization in writing as allowed by law. This would not affect any actions already taken based upon my original request. There are two ways to cancel this authorization:

Sign and date a revocation form. This form is available from WCPA; or
Write, sign and date a letter to WCPA to cancel the authorization.

I understand that once WCPA gives out information, WCPA has no control over it. The recipient might re-disclose it. Privacy laws may no longer protect it.

I understand that I am agreeing to the exchange of health care information regarding receiving testing and/or treatment for psychiatric disorders, mental health, behavior, and/or drug and/or alcohol use.

Consent(Required)

I fully understand and agree to the above stated terms.

Date(Required)

Time(Required)

First and Last Name of Patient or Legally Authorized Individual(Required)

Relationship to patient(Required)

if signed on behalf of the patient by parent, legal guardian, personal representative, etc.