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Record Releaserecord release form pdf

Submitting our Medical Release form* is necessary if you'd like your medical or behavioral health records shared with:

  • another medical or behavioral health provider
  • parents or guardians
  • another third party


A signed, submitted release form is required each and every time a request is made.

  • Our record release form is a fillable PDF
  • Please fill it out completely
  • Save it to your computer
  • Print it out
  • Sign the signature line
  • Email a photo of the two pages, save it as a PDF or jpg and email, or fax it


As our Notice of Privacy Practices fully outlines, we are required by law to obtain your authorization for any use or disclosure of your health information for purposes other than treatment, payment or health care operations.


*Adobe Reader is necessary to view this file. Download it free.


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Updated: July 20, 2016