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Patient Information: I give permission to release the Psychotherapy Notes of: (One patient per form) Patient Name: Date of Birth: Street Address: MR or last 4 numbers of City, State, Zip: Telephone: ( ) Email address: Release Information From: Release Information To: (List applicable Facility(s) and/or Practice(s) (Name of facility, person, company) (Relationship) (City, State, Zip Code) (Phone number) PURPOSE OF RELEASE (check reason): (Phone number) (Fax number) Request of individual/personal Legal purpose including discussions proceedings Continued patient care Insurance Other Fill in the dates of therapy sessions for Psychotherapy Notes to be released: Dates of therapy sessions: From: To FORMAT: (Check all that may apply) CD (charges may apply) Paper copy (charges may apply) Other DELIVERY METHOD: Reg.US Mail Pick-up Fax, where permitted Overnight/Express Mail Service, where permitted Secure email, where permitted Other: PATIENT’S RIGHTS – I understand that: I can cancel this permission at any time..
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