Records & Additional Services Request

Records & Additional Services Request
Client Name

First NameLast Name
Important Information About Records Requested for Court or Legal Purposes

Behavioral health records may contain highly personal and sensitive information, including diagnoses, symptoms, treatment history, assessments, treatment plans, clinical observations, and information discussed during services.

If records are requested for use in a court case or other legal matter, please understand that the information released may be disclosed to or reviewed by attorneys, opposing parties, court personnel, experts, or others involved in the proceeding. Once records are released for a legal purpose, Oceanic Counseling Group may not be able to control how the information is subsequently used, shared, discussed, or included in legal filings.

Depending on the purpose of your request, a more limited document—such as a treatment summary letter, attendance verification, or other specifically requested information—may be sufficient and may reduce the amount of sensitive information disclosed.

If you are requesting records for a court case, custody matter, disability claim, attorney, or other legal purpose, you may wish to discuss with your attorney and contact our office before submitting this form. Our Practice Relations Manager can discuss the available record options and help you determine whether a narrower request may meet your needs.

Contacting our office is optional and will not affect your right to request access to records to which you are legally entitled.
Your Name

First NameLast Name
Relationship to Client
N/A if you are requesting your own records.
Dates Requested
Records Fee Schedule

$20 processing fee + $0.65 per page for first 30 pages, $0.50 per page thereafter + Postage (if applicable)
Which records are you requesting:
Addition services not covered by insurance:
If you are an attorney or guardian of the Client, please provide evidence of representation:

Cancelof
Law Office Contact Information (if applicable)
Name & Phone Number
Acknowledgment
By signing below, I acknowledge that behavioral health records may contain sensitive and personal information. I understand that, when records are released for court or legal purposes, they may be reviewed or disclosed to other individuals involved in the proceeding.

I understand that this acknowledgment is informational only. It does not waive any applicable privilege or confidentiality protection, authorize disclosure beyond the scope of my request, or limit any legal rights I may have.
Signature

BY SIGNING BELOW You agree to the Fee Schedule above. Your signature below allows us to process the existing credit/debit card on file (checks are required for clients under representation).
Your Signature
Should be Empty:

Records & Additional Services Request

Records Fee Schedule

Signature