Mental Health Records Release Form
Patient Information
Full Name
Date of Birth
Address
Phone Number
Records to be Released
Release records to (Name/Organization):
Address
Phone Number
Fax/Email
Information to be released:
Reason for release:
Authorization
I authorize the release of my mental health records as described above.
This authorization will expire on:
If no date is specified, this authorization will expire 12 months from signature.
Signature
Date
I understand that I may revoke this authorization at any time by providing written notice.