Primary Care Physician Contact

At HEADS we strive to provide the most comprehensive treatment to the individuals we serve. Based on this, we are asking that you allow us to notify the Primary Care Physician of (client)
*
At any time that there is a need for communication between practitioners we will send a letter, along with the Release of Information that you sign. The other practitioner will be able to do the same. You may also request this at any point during treatment. Should you change or add providers we ask that you notify staff working with you so that we can update this information.
Please complete the following information in addition to the attached release of information.
Name of Primary Care Physician:
Telephone Number:
Fax Number:
Secondary Physician:
Telephone Number:
Fax Number:
Client or Legal Guardian Signature*
Printed Client or Legal Guardian Name*
Date*
Date Format: MM slash DD slash YYYY
*****This section shouldn’t be signed if the above information is completed*****

I, or the child I am parent/guardian to, currently do not have a PCP and understand that it has been recommended that I obtain one. Should I need assistance with this I will be referred to the Physician’s referral program in my area. Once obtained I will notify the clinician and/or coordinator assigned to my case so that the above process can be completed.
Client or Legal Guardian Signature
Printed Client or Legal Guardian Name
Date
Date Format: MM slash DD slash YYYY
*****This section shouldn’t be signed if the above information is completed and we can contact*****

I choose not to have my PCP or any other MD involved with my care be notified of my or my child’s involvement in mental health and/or psychiatric services. I understand that should I be prescribed medication or there be a significant event that warrants medical consultation this issue will again be discussed with me.
Client or Legal Guardian Signature
Printed Client or Legal Guardian Name
Date
Date Format: MM slash DD slash YYYY