Authorization for Release of Medical Information 2125 Belcourt Avenue, Nashville, TN 37212 Phone 615-379-8600; Fax: 615.269.3596

I, _______________________________________________(Name of patient), __________________________(Date of Birth), hereby give permission to The Nashville Center for Hope and Healing and Dr. Michelle Cochran, MD, Virginia Gardner, PMHNP-BC, Ellie Kenemer, PMHNP-BC, Leah Bowen PMHNP-BC and Lauren Valencia, LMSW to DISCLOSE information and/or OBTAIN information from/to: __________________________________________________________________________________________ __________________________________________________________________________________________ (Name of Clinician, Agency, Therapist, or Physician, including Address, phone, and fax number). Information to be disclosed/obtained: My mental health records in its entirety My substance abuse records in its entirety Psychotherapy notes ONLY THE FOLLOWING INFORMATION: Substance abuse evaluation Diagnosis and Treatment information Treatment recommendations Treatment plan Hospitalization Records Progress Reports Attendance Record Psychological Evaluation Labwork and Diagnostic studies Other (specified here) ____________________________________________________________ Form in which the information may be released: Verbal Photocopied Faxed Emailed The purpose for such disclosure: Continuity of Care Case management Other (specified here) _____________________________________________________________ This release shall be effective during the time I am under the care of the Clinician* (noted above). I may revoke this consent at any time except to the extent that the release has been completed.

Signature of Patient/or Guardian: _____________________________________________________________ Date of Signature: ______________ Witness for Signature: _______________________________________________________________________________________ This information has been disclosed to you from confidential records of which may be protected by federal and/or state law. Federal Regulation prohibits you from any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person whom it pertains or otherwise permitted. A general authorization for the release of medical or other information is not sufficient for this purpose.

2125 Belcourt Avenue, Nashville, TN 37212 Phone 615-269-0525; Fax: 615.269.3596