Release of Information Form

RBH Authorization for Release of Information
Date of Authorization to Release Information:

MonthDayYear
Authorization will remain valid for 1 year unless otherwise specified.
Patient Name

First NameLast Name
Birth Date

MonthDayYear
Person Providing Authorization:

First NameLast Name
Relation of Authorizing Party to Patient:
Authorizing Party Phone Number:

Area CodePhone Number
Authorizing Party Email:
example@example.com
I authorize the release of the following mental health records pertaining to the psychological services received at Restore Behavioral Health (check all that apply):
If Other, please specify information to be released:
Do you Authorize Specified Release of Information pertaining to Substance Abuse Assessment and Treatment?
Release Information to the Following:
Name of Individual with Whom Information is to be Released:

First NameLast Name
Name of Organization with Whom Information is to be Released:
Phone Number
Email Address
Fax Number:

Area CodePhone Number
Delivery Method
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature
Date

MonthDayYear
Date
Should be Empty:

RBH Authorization for Release of Information