Release of Information AuthorizationTo request & authorize the release of information to a third party Name * First Name Last Name I authorize current Latitude Mental Health Administrators to exchange the following written or verbal information: * Psychological Evaluation Treatment Summary Discharge or Transfer Summary Medication History Billing Information This information can only be shared with the following party * Recipient Name * Recipient Email Recipient Address Recipient Address This information will be exchanged for the following reason: * * Virtual Signature I understand that the medical record to be released may contain information pertaining to psychiatric and/or substance abuse, diagnosis, and treatment. I understand that I may withdraw this consent at any time prior to the release of the above information. This consent, if not withdrawn, will expire 180 days from the date below. Thank you!
