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Form

Release of Information Form

This form gives us permission to talk to your outpatient providers, family members, and critical members of your community. It is especially important that we are able to gather information from any previous or current hospitals, treatment facilities, or outpatient providers that you have seen in the past year. If you are 18+, please remember that we cannot speak to any family or community members without a Release of Information form.

This form gives us permissions to talk to your doctors, family members, and others you would like to have involved with your care. Please submit one form for each person.