Patient Information Release Authorization Form (pdf)
CCA Patient Mental Health Records Release Authorization Form (pdf) and instructions:
 

• All information must filled in. Do not leave any blanks.
• Circle the "release/receive" in the appropriate places.
• Question #1 - circle "to/from" in question #1. Make sure the mailing address is complete
• Question #2 - Specify purpose for record release. (For example; personal, continued care, legal, etc.) Records sent directly to another care giver are copied at no cost. All other types of copying will incur the standard patient fee.
• Question #3 and #4 - Specify what records are being requested and the dates.
• The authorization will expire 90 days from the date signed unless otherwise specified on the line above the signature line.
• Indicate at the bottom of the form if the records are to be mailed or picked up.

If you have any questions about these notices, please contact Health Information at (217) 383-3381.