Controlled Substance Release Authorization Form
Authorize the release of your controlled substance records or information. Please complete all fields to proceed.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Recipient Name or Organization
*
Recipient Contact Information
*
Purpose of Release
*
Please Select
Medical treatment
Personal use
Legal proceedings
Insurance
Other
Information to Be Released
*
Release Expiration Date
-
Month
-
Day
Year
Date
Signature
*
Submit Authorization
Submit Authorization
Should be Empty: