Release of Schedule Information

1
Patient Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Month
Day
Year
3
Name of Authorized Person* This field is required.The name of the person that you are authorizing to receive or communicate schedule information.
4
Authorized Person's Phone Number
Area Code
Phone Number
5
Would you like Grand Island Mental Health to release schedule details to the person listed above?* This field is required.This could include past appointment dates, future appointment dates, creating an appointment, and/or cancelling an appointment.
YESNO
6
This consent is active for duration of treatment or until terminated by client.
7
Was this a verbal release completed by a staff member of Grand Island Mental Health? * This field is required.
YESNO
8
Signature of Patient/Guardian
Clear
9
Name of staff member who took the verbal authorization:
Chantal Kohl
Mikki Lemmer
Amanda Porter
10
Today's Date
Date
Month
Day
Year
Should be Empty: