Mental Health Insurance Authorization to Release Records
Patient Information
Full Name
Date of Birth
Address
Phone
Recipient Information
Name/Organization
Address
Phone
Fax
Information to be Released
Purpose of Release
Authorization Terms
I authorize the release of the specified information to the recipient identified above.
I authorize verbal communication regarding my records.
This authorization expires on:
Patient Signature
Date
If patient is a minor or unable to sign, authorized representative:
Relationship
Additional Notes or Restrictions