[FORM 49—Use the top of this page for your letterhead.]Request/Authorization to Release Confidential Records and InformationI hereby authorize:Person or facility:Address:Phone:to release information from records about, born on,and whose Social Security number is, for the following purpose(s):qFurther mental health evaluation, treatment, or careqRehabilitation program development or servicesqTreatment planningqResearchqOther:These records concern the time betweenand.In the boxes below, the information to be disclosed is marked by an×; the items not to be released have a line drawnthrough them; page numbers are indicated when appropriate; and written dates indicate when those records weremailed to the requester.qIntake and discharge summariesqMedical history and evaluation(s)qMental health evaluationsqDevelopmental and/or social historyqEducational recordsqProgress notes, and treatment or closing summaryqOther:Select only one:qPlease forward the records to the address in the letterhead at the top of this form.
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Health care provider, records, Social Security number, mental health evaluation, Rehabilitation program development