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*

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Today's Date

Date