Release of Records Request

This form provides your therapist with permission to communicate with other individual providers regarding your treatment (e.g. previous treating therapist, current health care providers, parents or school).

Patient Information

First name

Last name

Address:

City

State

Zip

Phone

If patient is a minor, name of Parent/Guardian:

Provider Information

Name of Treating Therapist:

Treatment Dates:

Recipient Information

I authorize my Therapist to release my information to the following entity:

Name/Organization:

Attention:

Address:

City:

State:

Zip:

Phone number:

Records Requested

I authorize my Therapist to release/exchange the following information:

This authorization may be revoked at any time.

Name of Patient, Client or Authorized person:

Signature of Patient, Client or Authorized person:

North Carolina and Virginia

Release of Records Request

THE CLINIC

CONTACT