If you are requesting that copies of your records or a summary be sent to another provider (e.g. therapist, primary care doctor, etc.) I will need a current Release of Information form from you. Please be sure you are aware of the record fees for this release. The following form should be filled out, signed and dated then sent to me. To get the form to me:

1.) Click the link Release of Information Form below and the document will download to your computer. You will need to choose the download link according to your version of Microsoft Word. (Please note: On Windows 7 or 8 OS, downloads are found by clicking Start [flag in the lower left corner of your screen] → Computer → Downloads [in the menu on the left underneath Favorites]. If you cannot find it there, try clicking on the Start menu, and search for the Downloads folder or Release of Information Form.)

Release of Information Form (Recent Word versions)
Release of Information Form (Word '97 to '03 versions)

2.) Once you have found the file, double-click on it to open it. You may see that it opens in a "Protected View." Click on the Enable editing button on the yellow strip at the top of the document.

3.) To fill out the form by hand:
Print the document and fill it out completely (black or blue ink is best). Be sure to date and sign it.

To fill out the form electronically:
Type in all of your answers on the form. You will need to type your name in the signature line and it will be acknowledged as a valid electronic signature.

4.) To send in a hand-written form:
Scan the two pages to your computer and send both of the scanned document to me as attachments (at qolguidance@comcast.net). It is preferred that you fill it out by hand and scan it if possible. If you do not know how or are unable to scan a document, the document may be faxed to me (please send me an email requesting the fax number).

To send in an electronic form:
When you have finished filling the form out, be sure to save your changes. Close the document and send the document to me as an attachment (at qolguidance@comcast.net).

Please note: If you are unable to scan or attach the completed form, please email me for further directions.

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