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  • Authorization for the Release and Exchange of Confidential Information

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  • THE FOLLOWING INFORMATION:

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  • 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.

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  • Plymouth Psych Group, Plymouth, MN - Phone: 763-559-1640
    9655 Schmidt Lake Road, Suite 150, Plymouth, MN 55442

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