Release of Records

Note: Transitions Center MAY NOT release Mental Health Records directly to a patient without a review of the request and permission by the Provider (please ask for Request to Personally Obtain Mental Health Records Form).

I understand that this authorization is effective for a period of one year from the date of signature, unless otherwise specified below. No time frame may exceed one year from the date of signature. I understand that I have the right to revoke this authorization at any time by sending a written request to the person I authorized above to release the information. If applicable, specify another expiration date here:

(Facility or Person)

I have been told that in order to protect the limited confidentiality of records, my agreement to obtain or release is necessary and that this permission is limited for the purposes and to the entity listed above, and will be effective during the date listed below. I also understand that this consent is revocable except to the extent that records have been sent.

Request to Personally Obtain Mental Health Records

am formally requesting a copy of my Mental Health Records from Transitions Center. I am requesting my records for the following reason(s):