NBH Record Release

Record Release Request Form
Date of Request:*
Patient's Name:*

First NameLast Name
Date of Birth:*
Best Number:*

Area CodePhone Number
Purpose of Release*

Medical CareSchool or CampInsurancePersonalLegal MatterOther
Format of Release*

I would like my records emailed to me (enter email below).I would like my records mailed to me (enter address below).I would like my records faxed (enter fax below).I would like to pick up my records in the Norwood Office.I would like to pick up my records in the Franklin Office.
Release to*
First and Last Name
Relationship to Patient*
Self, Parent, Doctor, etc.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number

Area CodePhone Number
Email
example@example.com
Additional Info
Please note: This email is not encrypted. Records are sent in a pdf format to the email address entered with a password.

Psychotherapy Notes receive special protections by law. We do not release Psychotherapy Notes to parents. Please reference the link below for more information.

https://www.hhs.gov/hipaa/for-professionals/faq/2094/does-parent-have-right-receive-copy-psychotherapy-notes-about-childs-mental-health-treatment.html
Request Type*

Full medical recordOther (specify information to be released below)
Other
I hereby authorize Norwood Behavioral Health to release any medical information as requested above. This may include information about drug or alcohol use, psychiatric, social work, or other protected information unless otherwise excluded, such as psychotherapy notes. I am aware that Norwood Behavioral Health cannot control how the recipient uses or shares the information, and that laws protecting its confidentiality at Norwood Behavioral Health may or may not protect this information once it has been disclosed to the recipient.
Signature*

Clear
Name*

First NameLast Name
Relationship to Patient*
Should be Empty: