Make a Referral

Release of Information

Today's Date(Required)
Patient Name(Required)
MM slash DD slash YYYY
Address to release to(Required)
Information to Release(Required)
In signing below, I authorize the Mood Treatment Center to release the information checked to the designated party listed above. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Mood Treatment Center. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurance with the right to contest a claim under my policy. I understand that this authorization for disclosure is voluntary and that I need not sign this form to ensure healthcare treatment.