RELEASE OF INFORMATION - Capital Mental Health LLC

I,*

HEREBY AUTHORIZED CAPITAL MENTAL HEALTH TO OBTAIN INFORMATION PERTAINING TO THE TREATMENT OF

FROM THE FOLLOWING PROVIDER:

NAME*

ADDRESS*

PHONE/FAX:*

INFORMATION TO BE USED FOR THE PURPOSE OF:*

TREATMENT CARE AND COORDINATION
INDICATE THE SPECIFIC REASON

I UNDERSTAND THAT AUTHORIZATION SHALL REMAIN VALID FROM THE DATE OF MY SIGNATURE BELOW AND FOR 12 MONTHS THEREAFTER(OR SOONER IF SPECIFIED) ENDING

ON: (DATE AUTHORIZATION EXPIRES)*

I HAVE BEEN INFORMED THAT I MAY REVOKE THIS AUTHORIZATION BY WRITTEN OR ORAL COMMUNICATION WITH CMH AT ANYTIME. I CERTIFY THAT THIS FORM HAS BEEN FULLY EXPLAINED TO ME AND THAT I UNDERSTAND ITS CONTENTS.

SIGNATURE OF PATIENT*

DATE OF AUTHORIZATION*

PRINTED NAME*

Comments

This field is for validation purposes and should be left unchanged.