To request client records from A Renewed Mind, the “Authorization for Release of Information” form must be completed and signed by the client or legal guardian, if the client is a minor.
Please complete ALL fields on the form before signing and dating it. Incomplete fields may result in a delay to fulfilling the request for records. Any records that contain alcohol/drug use diagnosis, referral or treatment are protected by 42 Code of Federal Regulation Part 2 and require specific permission from the client to be released.
Client name and date of birth help us to select the correct records
Recipient information should include the preferred method to receive the information whether fax or mail. Records can be provided via email but will be encrypted and require password protection.
Type of information to be released should be checked or specified. No alcohol/drug diagnosis, referral, or treatment information will be disclosed without specifically identifying it as permitted to release.
Indicate the purpose of the disclosure.
The form may be returned to A Renewed Mind via
fax at 440-398-8135 or
email to firstname.lastname@example.org
A Renewed Mind will respond to the request for records within 30 days of receiving the request.