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Get NM Authorization to Disclose or Use Protected Mental Health Care Information

____ Patient’s Full Name ________/_______/_______ Date of Birth __________-_____-__________ Social Security No. The undersigned is the patient or the legally authorized patient's representative. I authorize ____________________________________________________________________________ (provider name) to disclose written mental health information from ___________________(date) to___________________ (date), (Initial ONLY those records to be released): __________ Psychotherapy notes __________.

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