Patient Forms – Couch & Cardigan PLLC

Release Of Information Form

Home Patient Forms

We take confidentiality seriously. Patients have the option to electronically request release of information (ROI) to and from other providers (e.g. therapists, primary care doctors, specialists) or loved ones.

Please fill out the form below and electronically sign to allow us permission to share medical information.

Please click on the “Submit” button when complete.

Your Name

Date of Birth

Best Phone Number to Reach You

Other Provider/Loved One: Information #1 (Name, Fax, Phone)

Other Provider/Loved One: Information #2 (Name, Fax, Phone)

Name of doctor at Couch & Cardigan

I am allowing the following information to be shared between medical providers

Further comments/instructions (optional. e.g. release my medical records; this is my therapist; this is my spouse) )

Electronic Signature (Please type in first and last name here)

Today's Date

Please check all of the following:

I am electronically signing the request for Release of Information (ROI) between Couch & Cardigan and the provider(s) above.

I understand that the ROI can be rescinded at any time with a written request.

Refill Request

The following is a medication refill request form. Controlled medications (examples: Adderall, Ritalin, Klonopin, Xanax) prescribed outside of scheduled appointments will be charged a $50 prescription refill fee. Please complete all sections and then hit the “Submit” button. Refills will be automatically denied if any section is missing.

Your Name

Date of Birth

Preferred Pharmacy (Please include address and phone number)

Medication being requested (e.g. Advil). Please include dose (e.g. 200 mg) and how you are taking the medication (e.g. twice a day)

Further comment/instructions (optional)

I understand that this is a refill request, and it does not mean that I will receive the requested medication. My doctor will carefully review the request and determine whether to approve it, deny it, or request a follow-up appointment.

Release Of Information Form

Please check all of the following:

Refill Request

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