Get Ca Dialectical Behavior Therapy Center Of San Diego Authorization For Release Of Mental Health 2012-2025

Filling out the CA Dialectical Behavior Therapy Center Of San Diego Authorization For Release Of Mental Health form online is a straightforward process that ensures your mental health records are shared with the appropriate professionals. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete your authorization form online.

1. Press the ‘Get Form’ button to obtain the authorization form and open it in your preferred digital format.
2. In the designated field, enter the name of the patient requiring the release of their mental health records.
3. Fill in the date of birth for the patient in the provided format: month, day, and year.
4. Next, identify the hospital or former therapist authorized to release information by writing their name and contact phone number.
5. Provide the address and fax number for the hospital or former therapist, ensuring the details are correct for easy communication.
6. Identify the agency that will receive the records by writing 'Dialectical Behavior Therapy Center of San Diego' in the specified section.
7. You will then indicate what specific information you authorize to be released. Initial next to each type of information, including diagnosis, medical history, psychological evaluation, treatment plan, progress notes, treatment summary, and any other information you wish to specify.
8. Note that the use of the released information is limited to assessment and treatment planning, and acknowledge that DBT Center of San Diego will not provide copies of this information back to the patient.
9. Specify the duration of the authorization, which is valid for one year from the date of your signature, unless you indicate a different expiration date.
10. Initial in the indicated space to confirm you have received a true copy of this authorization.
11. Print the name of the patient and, if applicable, their legal guardian. Ensure to include all required signatures clearly.
12. Finally, fill in the date when the form is being faxed or mailed. After reviewing all entries, save your changes and download or print the completed form for your records.

Complete your authorization for release of mental health records online today!