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Form49 - [FORM 49Use the top of this page for your...

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[ FORM 49 —Use the top of this page for your letterhead.] Request/Authorization to Release Confidential Records and Information I 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): q Further mental health evaluation, treatment, or care q Rehabilitation program development or services q Treatment planning q Research q Other: These records concern the time between and . In the boxes below, the information to be disclosed is marked by an × ; the items not to be released have a line drawn through them; page numbers are indicated when appropriate; and written dates indicate when those records were mailed to the requester. q Intake and discharge summaries q Medical history and evaluation(s) q Mental health evaluations q Developmental and/or social history q Educational records q Progress notes, and treatment or closing summary q Other: Select only one: q Please forward the records to the address in the letterhead at the top of this form.
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  • Spring '10
  • all
  • Health care provider, records, Social Security number, mental health evaluation, Rehabilitation program development

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