RELEASE OF INFORMATION

X/Twitter
This field is for validation purposes and should be left unchanged.
I,*
HEREBY AUTHORIZED CAPITAL MENTAL HEALTH TO OBTAIN INFORMATION PERTAINING TO THE TREATMENT OF
*
FROM THE FOLLOWING PROVIDER:
NAME*
First
ADDRESS*
Street 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)*
MM slash DD slash YYYY
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*
MM slash DD slash YYYY
PRINTED NAME*