Release of Information (former) 2025

1. Click ‘Get Form’ to open the Release of Information (former) in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the name, phone number, and address of the hospital or former therapist authorized to release information. This section is vital for ensuring that records are sent from the correct source.
4. Specify the agency receiving the records by confirming 'Dialectical Behavior Therapy Center of San Diego' is listed correctly.
5. Indicate which specific information you authorize to be released by placing your initials next to each category, such as Diagnosis, Medical History, Psychological Evaluation, etc.
6. Set an expiration date for this authorization if different from one year by filling in the appropriate field.
7. Sign and date the form at the bottom. If applicable, include legal guardian signatures where necessary.

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