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MENTAL HEALTH RECORDS AUTHORIZATION Place Label Harp: (618) 3957340 × 4091 F: (618) 3934215 1. PATIENT INFORMATION Patient Name: Street Address: Maiden/Other Name(s):Birthdate: City, State, Zip:
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How to fill out mental health records authorization

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How to fill out mental health records authorization

01
Obtain the mental health records authorization form from the appropriate healthcare provider or facility.
02
Fill out the form completely with accurate personal information such as name, date of birth, and contact information.
03
Specify the details of the mental health records you are requesting, including the timeframe and specific information needed.
04
Sign and date the authorization form to confirm your consent for the release of your mental health records.
05
Submit the completed form to the healthcare provider or facility either in person, by mail, or through an online portal.

Who needs mental health records authorization?

01
Individuals who are seeking access to their own mental health records for personal review or to share with another healthcare provider.
02
Family members or legal guardians who are authorized to request mental health records on behalf of a minor or incapacitated individual.
03
Legal representatives or advocates who are supporting an individual in obtaining their mental health records for legal or healthcare purposes.
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Mental health records authorization is a legal document that allows an individual to give permission for their mental health records to be shared with specific individuals or organizations.
Individuals who wish to authorize the release of their mental health records are required to file mental health records authorization.
To fill out a mental health records authorization, an individual must provide their personal information, specify who can access their mental health records, and sign the document.
The purpose of mental health records authorization is to protect the privacy and confidentiality of an individual's mental health information.
A mental health records authorization must include the individual's name, date of birth, the specific information to be disclosed, the purpose of disclosure, expiration date, and signatures of both the individual and the authorized recipient.
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