Get The Counseling Center One Main St Nashua Nh - Formsite

This guide will help you understand how to complete the Counseling Center authorization form online. By following these step-by-step instructions, you can easily provide the necessary authorizations for information release and obtain the required records efficiently.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by filling out the name, date of birth, account number, and document ID fields at the top of the form.
3. In the section labeled 'To Obtain Records or Information from Outside Agency or Provider,' you must initial to authorize an outside agency or provider and specify the name of that agency.
4. Select the types of records or information you wish to obtain by checking the appropriate boxes, which include options for all medical records, verbal disclosures, and limited records.
5. If needed, specify any limitations on the records being requested, such as specific dates or types of records in the provided fields.
6. Next, in the 'To Release Counseling Center Records or Information' section, initial to authorize the Counseling Center to release your information to designated individuals or agencies.
7. Again, select the types of records or information you would like to be released by checking the relevant boxes.
8. You may specify date limitations for the records if applicable.
9. Review the section about revocation of this authorization to understand your rights.
10. Provide your signature, date, relationship to the patient, and witness information if applicable. Make sure to include contact information for the provider or recipient.
11. Finally, save your changes, and if you need to, you can download, print, or share the completed form as needed.

Complete your documents online effortlessly today.