Communication Forms

The following consultation and disclosure forms were developed in collaboration with the NC Medical Society for use between specialists to ensure appropriate information sharing while preserving confidentiality.

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/Disclosure of Psychotherapy Notes)

Medico-Legal Guidelines, jointly approved by the NC Bar Association and NC Medical Society, were revised in 2009 to the include information on appropriate release of substance abuse and mental health records and psychotherapy notes. The guidelines cite federal and state laws concerning release of these specific medical record sets and contain authorization forms for release of health information and psychotherapy notes and a sample court order allowing release of mental health, substance abuse, and/or psychotherapy records.

Physician Referral and Feedback Form from the American Academy of Pediatrics. Assists providers in facilitating communication and treatment after evaluation of a patient.  Includes initial diagnoses, recommendations, medications prescribed, and a followup plan.

Referral forms are offered by CCNC to facilitate consultation and communication between primary care and behavioral health providers: behavioral health request for information, referral to behavioral health services, and behavioral health feedback to primary care.

NC practices offer these helpful forms:

Behav. Health Report Request-Community Care of the Lower Cape Fear
Referral Information Detailed Guide-Community Care of the Lower Cape Fear
PCP Referrral Algorithm-Crisis
-Community Care of the Lower Cape Fear
PCP Referrral Algorithm-Routine
-Community Care of the Lower Cape Fear
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