RELEASE OF INFORMATION - Capital Mental Health LLC

I,

First NameLast Name
HEREBY AUTHORIZE CAPITAL MENTAL HEALTH TO PROVIDE OR OBTAIN INFORMATION PERTAINING TO THE TREATMENT OF
First NameLast Name
TO/FROM THE FOLLOWING PERSON(S) OR TYPE OF PERSON(S):
Name
Phone/Fax
Please enter a valid phone number.Format: (000) 000-0000.
Name
Phone/Fax
Please enter a valid phone number.Format: (000) 000-0000.
Name
Phone/Fax
Please enter a valid phone number.Format: (000) 000-0000.
INFORMATION TO BE USED FOR THE PURPOSE OF:*
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)
PRINTED NAME*
Signature
Today's Date

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2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: