Ijeoma Ajufo MD
Northridge Behavioral Health
2829 Babcock Road, Tower 1, Suite 126
78229, Phone - 2104753048
CONSENT TO RELEASE/RECEIVE CONFIDENTIAL INFORMATION
I authorize at the above address to:
Receive my medical history information from the following physicians:
Receive my treatment records from the following therapist:
Release my treatment information/records to the following healthcare professionals:
Release my treatment information to the health insurance company listed below for billing / authorization purposes.
This information is for the following purposes (any other use is prohibited).
I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken in reliance on it. This consent will last while I am being treated by the physician specified above unless I withdraw my consent during treatment. This consent will expire 5 years from date of signature.
I understand that the records to be released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illness. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient.
I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights.