Release of Information Form - Four County Mental Health Center 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient’s name, case number, and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the last four digits of the social security number. This helps verify the patient's identity and maintain confidentiality.
4. In the section for authorization, specify the individual or organization that will receive or provide information. Include their address, city, state/zip, and phone number.
5. Select which specific information you are authorizing to be released by checking the appropriate boxes. Options include treatment summaries, medical records, and more.
6. Indicate the purpose of this release by selecting from provided options or specifying your own needs.
7. Sign and date the form at the bottom. If applicable, a parent or guardian should also sign and provide their relationship to the patient.

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