Release of Information - Non-confidential
Davidson Forensic Group
Pacific Northwest: 800 W. Main STE 1460, Boise, ID 83702
Southwest, Midwest and East: 6860 North Dallas Pkwy STE 200, Dallas, TX 75204
Office (208) 401-9292 Fax (888) 567-9673
 

Please Fax Records To (888) 567-9673 or Email jamie@davidsonforensicgroup.com

INFORMATION IS NOT CONFIDENTIAL AND IS FOR LEGAL PURPOSES RATHER THAN HEALTHCARE

I hereby authorize release of information for myself or my child:

INSTRUCTIONS ON HOW TO COMPLETE THE RELEASE FORM: Release forms are required for Dr. Davidson to obtain information from other people about you or your children. There are two groups of people from whom information is requested.
 
The first group includes Professionals/Institutions/Organizations. This group typically includes primary care physicians, specialty physicians, counselors, hospitals, speech therapists, schools and so forth that will provide records concerning you.
 
The second group includes Personal Parenting References (i.e. Friend/Family/Associates). This group typically includes people that can make a report about your parenting abilities and mental stability. Please provide five people in this group as references. 
 
As an example of the difference between the two groups, understand that records regarding your child would be requested from a school district (an institution), while a teacher in the school district commenting on your parenting abilities would be a report. Therefore, a fax # would be necessary to obtain records from the school. An email address would be necessary to obtain a report from the teacher. 
 
> Complete a release with fax # for each Professional/Institution/Organization for you in the last 5 years. 
> Complete a release with fax # for each Professional/Institution/Counselor for your child in the last 5 years. Your child's name should be at the top of the release if the release is for their counselor, school, pediatrician etc. Your name should be at the top of the release for your physician, counselor etc.
> Complete a release with email address for each Friend/Family/Associate that you would like us to contact.
 
A new release form is generated by clicking on the "release form" link on Dr. Davidson's website. Please email Dr. Davidson if you have difficulties or need help completing the release forms: davidsonpsych@me.com.
Check off the category of release as you go. This will help you keep track of the organizations and people that may need a release.
 

Release Information for the Adult or Child Named Below

I hereby authorize the use and/or disclosure of my protected health information, school and/or work records as described in this authorization to Dr. James Davidson:

Type of Release *
This release is freely given and authorizes Dr. Davidson to request all my records and/or discuss me and/or my children verbally or in writing. The purpose for this request of records is legal rather than healthcare  in order to complete a court ordered or court related psychological evaluation. I understand and agree that all information released with this authorization is NOT confidential. My signature indicates that ALL rights and privileges to confidentiality are waived. 
 
I understand that this authorization extends to all of the records/information designated below which may include school/day care records, work records, medical records, behavioral health records including drug/alcohol abuse, HIV/AIDS test results or diagnosis, genetics, agency records, court and police documens. The information to be released includes the following:
 
[X ] Entire File         AND/OR        [X ] Interview or Questionnaire         
 
This authorization is to be disclosed to Dr. James Davidson or his staff. I hereby release the Person or Entity releasing information from all legal responsibilities or liability that may arise from the release, use or disclosure of this information. 
 
1. Expiration. I understand that unless I revoke this authorization earlier, this authorization will automatically expire in 180 days, or according to the relevant state or federal law, from the date this authorization is signed. 
2. Re-Disclosure. I understand that information used or disclosed in accordance with this authorization may no longer be protected by HIPAA, and could be used or redisclosed by the receiving party. I further authorize redisclosure of any and all records protected by 42 CFR part 2. 
3. Certification. I certify that I am the individual named in this release, or the individual's authorized representative, and that the identification and proof of authority that I have provided is true and correct.
4. Revocation. I understand that I may revoke this authorization at any time by notifying Dr, Davidson in writing at 800 W. Main St STE 1460, Boise, Idaho 83702. I understand that the revocation is only effective after it is received and logged by Dr. Davidson. I also understand that any use or disclosure made prior to the recovation under this authorization will not be affected by a revocation.  
5. Copy. I understand that I am entitled to receive a copy of this completed form upon request.
6. Treatment. I understand that Dr. Davidson and Davidson Forensic Group will not condition treatment based on my signing this authorization. Further, I understand that no treatment is being provided since the purpose of this release is to obtain records per the order of the court. 
7. Original. I understand that a photocopy, fax or pdf of this authorization is as valid as the original.
8. Signature. My signature on this form is signed by my hand on a computer. I hereby certify that the signature on this release is mine, and shall be used in lieu of my handwritten signature.
 
 
Signed (Please use your mouse or finger)
 *
clear
I am signing this form as: *
I certify that I am the individual named in this release, or the individual's authorized representative, and that the identification and proof of authority that I have provided is true and correct. I further warrant that, in the case that this release is for my child, I am authorized as a parent to sign this release on behalf of my minor child.  
For the recipient of this information: if any of the requested records contain information regarding alcohol or drug abuse treatment, it may be protected Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further use or disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the use or release of medical or other information is not sufficient for this purpose.