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  • Release of Information / Medical Records Request

  • By signing this form, I authorize Premier Mental and Behavioral Services to receive or release confidential medical information about me, by receiving or releasing a copy of my medical records, or a summary or narrative of my protected health information or a discussion of my treatment with the parties listed below:

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  • This release is valid for one year unless otherwise specified below. All records may be included with the exception of therapy progress notes as they are protected information and cannot be released. Please be advised that any records requested from our office may take up to 14 calendar days to be completed. Any requests being forwarded to another healthcare provider will be free of cost. However, records being released to any other entity including self will have a cost associated with it.

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