ESSEX COUNTY MENTAL HEALTH SERVICES PO BOX 8 7513 COURT - co essex ny-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name, date of birth, and social security number in the designated fields at the top of the form.
3. In the authorization section, specify whether you want Essex County Mental Health Services to obtain information from another person or agency by filling in their details.
4. Indicate who will receive the information by completing the 'provide to' section with their name, address, phone, and fax numbers.
5. Select the specific information you wish to release by checking the appropriate boxes related to treatment plans, evaluations, and other records.
6. State the purpose for releasing this information by checking one or more options provided on the form.
7. Choose how long this authorization will remain valid by selecting one of the expiration options listed.
8. Sign and date the form at the bottom. If applicable, have a witness sign as well.
9. If you need to cancel this authorization later, complete the cancellation section at the end of the document.

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