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  • I authorize Austin Mind and Behavioral Health, its providers and its staff to use, obtain or disclose information about myself or for a minor (under the legal age of 18), for whom I am the legal guardian. The information may be disclosed to the following:

  • Purpose of disclosure of information:

    1. I fully understand and give this authorization, voluntarily without coercion.
    2. I understand that a fax copy or a photocopy of this authorization will be considered as valid as the original.
    3. I understand that this authorization is valid for one year from the date of signature.
    4. I understand that I can revoke this authorization at any time by notifying Austin Mind and Behavioral Health.
    5. I understand that I can request and receive a copy of this form.

    With my signature below, I acknowledge that I have read and understand this authorization for release of information.

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  • This field is for validation purposes and should be left unchanged.