ROI | Neuro Nudge

Neuro Nudge Release of Information

Patient Information:

Patient name:

Birthday

Month

Day

Year

Phone

Purpose of Disclosure:

I authorize Neuro Nudge Psychiatry PLLC to release, obtain, or exchange my protected health information (PHI) for the following purpose(s):

Choose all that apply:

Information to be released or obtained:

Choose all that apply:

Entities Authorized to Receive or Share Information

(You may list multiple)

Name/Organization:

Address:

Phone:

Fax:

Name/Organization:

Address:

Phone:

Fax:

Name/Organization:

Address:

Phone:

Fax:

Examples of permissible entities: employers, HR departments, schools, universities, therapists, counselors, psychologists, psychiatrists, primary care physicians, specialists, hospitals, residential programs, case managers, attorneys, or any other party the patient designates.

Your Rights and Important Information (Required by HIPAA & Texas Law)

This authorization is voluntary. Neuro Nudge Psychiatry PLLC will not base treatment on signing this form.
You may revoke this authorization at any time by submitting a written request. Revocation does not apply to information already released.
Texas HB 300 provides enhanced protection for mental‑health information. Neuro Nudge will only disclose the minimum necessary information required for the purpose you select.
This authorization allows two‑way communication between Neuro Nudge Psychiatry PLLC and the listed entities unless you specify otherwise.
Psychotherapy notes require a separate authorization under HIPAA and are not included unless specifically initialed above.
Information disclosed may be re‑released by the receiving party and may no longer be protected by HIPAA.
Expiration: This authorization expires on:

Choose one:

One year from signature

Upon completion of the purpose

Indicate Specific Date:

Date

Month

Day

Year

Patient Consent

I understand the information above and authorize Neuro Nudge Psychiatry PLLC to release, obtain, or exchange my protected health information with the entities listed.

Patient's Name:

Patient or Parent/Guardian's Signature:

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**Upon successful completion of this form you will receive an email confirmationa and be redirected back to the Forms page.**