Plymouth Psych Group Release of Information

Authorization for the Release and Exchange of Confidential Information
Patient Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone:

Area CodePhone Number
I authorize Plymouth Psych Group to:
Name of party that will be receiving OR releasing information:
Can be a school, teacher, parent, case manager, doctor, etc.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone

Area CodePhone Number
What action would you like for us to take?

Other
Fax

Area CodePhone Number
THE FOLLOWING INFORMATION:
Most Recent Evaluation + Last 3 progress notes
Date From:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Date To:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Please check all that apply
I am requesting this information be released for the following purpose:

Other
If the records need to be mailed or physically picked up, specify here.
Mailing or Email Address
With the exception of psychotherapy notes, all records pertaining to psychiatric mental health, chemical dependency and/or AIDS/HIV related illness/testing will be released unless otherwise indicated by a check mark here:
Please specify any restrictions to the request (if any)
I understand that this authorization for release of medical records remains in effect indefinitely unless revoked by me. Revocation must be in writing and submitted to the address listed on this form. If no expiration date is specified, this authorization is valid until revoked.

Once information is released, Plymouth Psych Group cannot control its further disclosure. Completion and signature are required for validity. A copy of this authorization is as valid as the original bearing my signature.

I understand there may be a charge associated with the Release of Information Services rendered. There is no charge for release of information to other health care facilities.
Name/Signature of Legal Representative
Name/Signature of Client if 16 or older
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Enter the message as it's shown
Plymouth Psych Group, Plymouth, MN - Phone: 763-559-1640
9655 Schmidt Lake Road, Suite 150, Plymouth, MN 55442
Should be Empty:

Authorization for the Release and Exchange of Confidential Information

THE FOLLOWING INFORMATION: