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 PROVIDER:
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone/Fax*
Please enter a valid phone number.
INFORMATION TO BE USED FOR THE PURPOSE OF:**

TREATMENT CARE AND COORDINATION
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*

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