Consent to Release Psychiatric / Medical / Alcohol / Drug Abuse Records

Please correct the errors described below.

under the conditions listed below

(Specific Date, Event or Condition)

4. An additional consent must be obtained for any other transfer or disclosure of this information.

5. I understand that I may receive a copy of this release.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

(where required indicate which)

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