Mental Health Medical Authorization Release Form

Patient Information

Name

Date of Birth

Phone Number

Address Insurance ID Number

Recipient of Information

Name of Person or Organization Address/Fax/Email

Provider/Facility Information

Name of Provider/Facility Address Phone

Information to be Released

Purpose of Release

Authorization

I authorize the above-named provider/facility to release the specified information to the insurance carrier or related organization for the purpose stated above. I understand that this authorization is voluntary and that I may revoke it at any time in writing.

Effective Date

Date Authorization Expires

Signature of Patient/Authorized Representative Date

If Representative, Describe Authority