Consent for Release of Confidential Medical/Psychiatric, Substance Abuse or HIV Information

Please correct the errors described below.
Today's Date
Name of Referral Source

I understand that treatment services are not contingent upon my signing this release. I also understand that thsi consent is subject to revocation, in writing, at any time, except to the extent that the facility/provider has already taken action.

This authorization for release of information is valid from (date given below) until written notice by myself is given and actually received and processed by Comprehensive Mental Health Services.

(if 14 years of age or older)

Your message will be encrypted and can only be read by Comprehensive Mental Health Services.