Behavioral Health Services for Wyoming & Colorado

Accepting New Patients!

(307) 426-4797

Records Request Form

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Records Request Form

Call us today

(307) 426-4797

Email Address

info@specialtycounseling.com

Location

4025 Rawlins Street
Cheyenne, WY 82001

Office time

Mon – Fri, 8am to 5pm

Specialty Counseling & Consulting Records Release Form

Please fill out the form below, and someone from the SCC team will get back to you promptly. If you would prefer to print the form and fill it out manually, you may do so by clicking here.

Release of Information

I hereby authorize Specialty Counseling and Consulting to Release/Receive information

Information to be:
Please check the appropriate requested information:

The purpose of this release of information is to facilitate treatment and coordinate care between providers.

I/we understand that my or my child's records are protected under the State and Federal Confidentiality Regulations and cannot be disclosed without my permission. I also understand that I may revoke my consent for disclosure in writing at any time, except that action has been in reliance on it and that in any event, this consent expires automatically as described below.

I/we understand this Authorization of Release Form is effective for one year from the date of signature below or is discharged from therapy services while under the care of the Therapist.

Typing your name in this field acts as a signature for this form.

FEDERAL LAW (42CFR, Part 2) prohibits making any further disclosure of this information without the specific written consent of the person to whom it pertains. A general authorization for the release of information is NOT sufficient for this purpose. Per Substance Abuse Requirements Federal Law (45CFR), 160 & 164) also applies.