{"id":847,"date":"2024-06-11T16:52:10","date_gmt":"2024-06-11T16:52:10","guid":{"rendered":"https:\/\/www.nepvneuro.com\/?page_id=847"},"modified":"2024-06-11T16:55:58","modified_gmt":"2024-06-11T16:55:58","slug":"release-of-information-form","status":"publish","type":"page","link":"https:\/\/www.nepvneuro.com\/?page_id=847","title":{"rendered":"Release of Information Form"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;3.0.100&#8243; background_image=&#8221;http:\/\/www.nepvneuro.com\/wp-content\/uploads\/2018\/12\/what-is-Neuropsychology.jpg&#8221; parallax=&#8221;on&#8221;][et_pb_row _builder_version=&#8221;3.0.48&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.0.47&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_divider show_divider=&#8221;off&#8221; height=&#8221;100px&#8221; _builder_version=&#8221;3.2&#8243;][\/et_pb_divider][et_pb_text _builder_version=&#8221;3.0.100&#8243; text_font=&#8221;|700|||||||&#8221; text_font_size=&#8221;50px&#8221; text_text_shadow_style=&#8221;preset1&#8243; background_layout=&#8221;dark&#8221;][\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;3.6&#8243; parallax=&#8221;on&#8221;][et_pb_row _builder_version=&#8221;3.6&#8243;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.6&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][wpforms_selector form_id=&#8221;749&#8243; _builder_version=&#8221;3.6&#8243; show_title=&#8221;on&#8221;][\/wpforms_selector][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<div class=\"et_pb_module wpforms_selector wpforms_selector_0\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t<style id=\"wpforms-css-vars-749\">\n\t\t\t\t#wpforms-749 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-749\"><form id=\"wpforms-form-749\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"749\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F847\" data-token=\"c947dbafef35f4cfd578842e302201e6\" data-token-time=\"1791907650\"><div class=\"wpforms-head-container\"><div class=\"wpforms-title\">Medical Records Release Form<\/div><\/div><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-749-field_1-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"1\"><h3 id=\"wpforms-749-field_1\" aria-errormessage=\"wpforms-749-field_1-error\">Patient Information<\/h3><\/div><div id=\"wpforms-749-field_2-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"2\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-749-field_3-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_3\">Full Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-749-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" placeholder=\"e.g., Jane Doe\" aria-errormessage=\"wpforms-749-field_3-error\" required><\/div><div id=\"wpforms-749-field_5-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_5\">Contact Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-749-field_5\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][5]\" aria-label=\"Contact Number\" aria-errormessage=\"wpforms-749-field_5-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-749-field_4-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_4\">Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-749-field_4\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][4][date]\" placeholder=\"MM\/DD\/YY\" aria-errormessage=\"wpforms-749-field_4-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-749-field_6-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_6\">Email Address<\/label><input type=\"email\" id=\"wpforms-749-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" placeholder=\"e.g., janedoe@example.com\" spellcheck=\"false\" aria-errormessage=\"wpforms-749-field_6-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-749-field_24-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">I hereby authorize Neponset Valley Neuropsychology, LLC to (check all that apply)<\/legend><ul id=\"wpforms-749-field_24\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-749-field_24_1\" name=\"wpforms[fields][24][]\" value=\"RECEIVE COPIES OF MY MEDICAL RECORD FROM:\" aria-errormessage=\"wpforms-749-field_24_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-749-field_24_1\">RECEIVE COPIES OF MY MEDICAL RECORD FROM:<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-749-field_24_2\" name=\"wpforms[fields][24][]\" value=\"RELEASE COPIES OF MY NEUROPSYCHOLOGICAL REPORT TO:\" aria-errormessage=\"wpforms-749-field_24_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-749-field_24_2\">RELEASE COPIES OF MY NEUROPSYCHOLOGICAL REPORT TO:<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-749-field_24_3\" name=\"wpforms[fields][24][]\" value=\"DISCUSS MY ONGOING EVALUATION WITH:\" aria-errormessage=\"wpforms-749-field_24_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-749-field_24_3\">DISCUSS MY ONGOING EVALUATION WITH:<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-749-field_8-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"8\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-749-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_9\">Primary Care Provider or Group Practice<\/label><input type=\"text\" id=\"wpforms-749-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" placeholder=\"e.g., City Hospital\" aria-errormessage=\"wpforms-749-field_9-error\" ><\/div><div id=\"wpforms-749-field_10-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_10\">Additional Provider<\/label><input type=\"text\" id=\"wpforms-749-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" placeholder=\"e.g., John Smith\" aria-errormessage=\"wpforms-749-field_10-error\" ><\/div><div id=\"wpforms-749-field_26-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_26\">Additional Provider<\/label><input type=\"text\" id=\"wpforms-749-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" placeholder=\"e.g., John Smith\" aria-errormessage=\"wpforms-749-field_26-error\" ><\/div><div id=\"wpforms-749-field_27-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_27\">Other<\/label><input type=\"text\" id=\"wpforms-749-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\" placeholder=\"e.g., John Smith\" aria-errormessage=\"wpforms-749-field_27-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-749-field_12-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_12\">Phone Number<\/label><input type=\"tel\" id=\"wpforms-749-field_12\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][12]\" aria-label=\"Phone Number\" aria-errormessage=\"wpforms-749-field_12-error\" ><\/div><div id=\"wpforms-749-field_28-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_28\">Phone Number<\/label><input type=\"tel\" id=\"wpforms-749-field_28\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][28]\" aria-label=\"Phone Number\" aria-errormessage=\"wpforms-749-field_28-error\" ><\/div><div id=\"wpforms-749-field_29-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_29\">Phone Number<\/label><input type=\"tel\" id=\"wpforms-749-field_29\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][29]\" aria-label=\"Phone Number\" aria-errormessage=\"wpforms-749-field_29-error\" ><\/div><div id=\"wpforms-749-field_30-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_30\">Phone Number<\/label><input type=\"tel\" id=\"wpforms-749-field_30\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][30]\" aria-label=\"Phone Number\" aria-errormessage=\"wpforms-749-field_30-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-749-field_31-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"31\"><fieldset><legend class=\"wpforms-field-label\"><\/legend><ul id=\"wpforms-749-field_31\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-749-field_31_1\" name=\"wpforms[fields][31][]\" value=\"I hereby authorize Neponset Valley Neuropsychology, LLC to discuss all details related to my evaluation and care with:\" aria-errormessage=\"wpforms-749-field_31_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-749-field_31_1\">I hereby authorize Neponset Valley Neuropsychology, LLC to discuss all details related to my evaluation and care with:<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-749-field_35-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"35\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-749-field_32-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_32\">Family<\/label><input type=\"text\" id=\"wpforms-749-field_32\" class=\"wpforms-field-medium\" name=\"wpforms[fields][32]\" placeholder=\"e.g., John Smith\" aria-errormessage=\"wpforms-749-field_32-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-749-field_36-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_36\">Phone Number<\/label><input type=\"tel\" id=\"wpforms-749-field_36\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][36]\" aria-label=\"Phone Number\" aria-errormessage=\"wpforms-749-field_36-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-749-field_33-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_33\">Other<\/label><input type=\"text\" id=\"wpforms-749-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" placeholder=\"e.g., John Smith\" aria-errormessage=\"wpforms-749-field_33-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-749-field_37-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_37\">Phone Number<\/label><input type=\"tel\" id=\"wpforms-749-field_37\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][37]\" aria-label=\"Phone Number\" aria-errormessage=\"wpforms-749-field_37-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-749-field_38-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"38\"><fieldset><legend class=\"wpforms-field-label\"> <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-749-field_38\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-749-field_38_1\" name=\"wpforms[fields][38][]\" value=\"I understand that once Neponset Valley Neuropsychology, LLC, discloses my health information to the recipient, Neponset Valley Neuropsychology, LLC, cannot guarantee that the recipient will not disclose my health information to another party. I have read and understand the terms of this authorization. By my signature below, I hereby knowingly and voluntarily authorize Neponset Valley Neuropsychology, LLC, to use or disclose my health information in the manner described above.\" aria-errormessage=\"wpforms-749-field_38_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-749-field_38_1\">I understand that once Neponset Valley Neuropsychology, LLC, discloses my health information to the recipient, Neponset Valley Neuropsychology, LLC, cannot guarantee that the recipient will not disclose my health information to another party. I have read and understand the terms of this authorization. By my signature below, I hereby knowingly and voluntarily authorize Neponset Valley Neuropsychology, LLC, to use or disclose my health information in the manner described above.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-749-field_20-container\" class=\"wpforms-field wpforms-field-signature\" data-field-type=\"signature\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-749-field_20\">Signature of Authorized Representative <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-749-field_20\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][20]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-749-field_20-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\" data-input-method=\"draw\"><canvas class=\"wpforms-signature-canvas\" 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