Permission to Release Mental Health Record

Please correct the errors described below.

Information to be Released

You are hereby authorized to furnish the following from my or my child's mental health record:

There is a $45 administrative charge for the first 20 pages and $1 per page thereafter. *There is NO fee for record requests made by government agencies (i.e. Unemployment office, SSI, etc.)*

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

Your information will be encrypted.