Coordination of Care Coordination of Care with Primary Care Provider or other Mental Health Provider Please fill out and submit the form below. If you are human, leave this field blank. Insurance companies request that we coordinate care with your primary care provider and any other mental health professionals with whom you are working. While we ask all patients, the decision as to whether about communication occurs is yours. In the areas below please indicate whether you do, or do not, give permission for your Mynd Matters clinician to communicate with your other provider(s). If you do give permission, please share their contact information with us on this form. Thank you for completing this form. Name * Email * Date * Mynd Matters Provider * Patient DOB * Permission to release information about my treatment to my Primary Care Provider or other attending physician/provider. * I GIve Permission I Do Not GIve Permission Primary Care Provider Name Phone FAX Permission to release information about my treatment to my Mental Health Care Provider. * I GIve Permission I Do Not GIve Permission Outside Mental Health Provider Name Phone FAX Signature Draw It Type It Clear
