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Communication Forms
Consultation Forms PDF Print E-mail

The following consultation and disclosure forms were developed in collaboration with the NC Medical Society for use between specialist.

ICARE Process and Policy Change Committee Consultation Form - this form was developed by the ICARE Process and Policy Change Committee.

 Appendix G-1 Sample Authorization Form (Disclosure of Health Information)

Appendix G-2 Sample Authorization Form (PHI)

Appendix G-3 Sample Authorization Form (Regarding Psychiatry Notes)

Appendix G-4 Sample Authorization Form (Use and Disclosure Regarding Psychiatry Notes)

"The NC Bar Association Medico Legal Liaison Committee has approved revisions to the Medico Legal Guidelines that newly include information on appropriate release of substance abuse and mental health records and psychotherapy notes.  The Guidelines include an explanation with cites to federal and state laws concerning release of these specific medical record sets.  In addition, the revised Guidelines also contain the following new and revised forms:  (1) revised patient/personal representative authorization to release general health information that includes mental health and substance abuse records; (2) new patient/personal representative authorization to release psychotherapy notes; (3) new sample court order allowing release of mental health, substance abuse, and/or psychotherapy records.  The new edition of the Medico Legal Guidelines will be formally published in the NC Rules of Court in 2010 following approval by the NC Bar Association and NC Medical Society.  The Committee that drafted these revisions is composed of attorneys who regularly represent hospitals, physicians, health insurance companies, other medical providers, and other related entities."

Click here for a Physician Referral and Feedback Form from the American Academy of Pediatrics.  

This template offered by the American Academy of Pediatrics assists providers in facilitating communication and treatment after evaluation of a patient.  Fields for information include referring physician's contact information, patient information, reason for referral, any specific questions or requests, initial diagnoses, recommendations, medications prescribed, and a follow up plan.

Other forms available:

Behavioral Health Report (KNOX)   Also see:  Referral Information Detailed Guide

Buncombe County Psychiatric Referral Form

Cabarras County Medical Consultation Form

Cabarras County Psychiatric Consultation Form 

El Futuro Referral Form

Gaston County Consent Form

Gaston County Consent for Minor Form

Gaston County Authorization Form

Guilford County Consult Form

MAHEC Psychiatric Consultation Form 

Referral Form (North Central Pilot)

WHN Communication Bulletin

WHN Communication Tool