Please complete all required fields marked with *
Client First Name *
Client Last Name *
Date of Birth *
Social Security #
If these records contain any information from previous providers or information about HIV (AIDS) status, cancer diagnosis, drug or alcohol abuse, OR sexually transmitted disease, you are hereby authorizing disclosure of this information.
Please Initial
Would you like Capstone Behavioral Health Services to Receive or Send Records *
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Name of Office or Person
Address
Phone Number
Fax Number
Date Range of Information
Chart NotesLab ResultsEKG ResultsPsychological TestingHospital RecordsFormLetterCoordination of Care
Purpose of this Request
Additional Information
Client Signature *
If client is a minor, this would be the signature of parent or guardian.
Today's Date *
I understand that the confidentiality of drug and alcohol abuse patient records maintained by this facility is protected by Federal Law 42 CFR Part 2. This information will not be released without the permission of the patient.
This authorization may be revoked or otherwise modified. This release will expire in ONE year from the date signed by the patient, parent, or guardian.
