Request for Mental Health Records Authorization - Rev. 9 - 2 - 2025

Sep 15, 2026

Uploaded by Rhys

Authorization form for requesting mental health records from a specific practice. One form covers one records request per practice, with required client and requester details, delivery method selection, and request purpose and included information. Processing takes 15 days and requires proper authorization and payment. Fees cover standard records, optional postage for paper, notary costs, and affidavit requests, along with client consent acknowledgements covering discretion, revocation limits, privacy redaction, and electronic risks.

LanguageEnglish

CategoryForms

FormatPDF

Pages3

Reading Time1 min

AccessFree to download

Client Information

Requestor Information

Recipient Information

Delivery Method

Purpose of Request

Availability for Consultation

Standard or Affidavit Request

Conditions and Fees

Acknowledgement and Consent

Signature and Date

Request for Mental Health Records Authorization Each authorization form allows for one request for mental health records per each practice. Submit completed form and documents to: Email: Scheduling@Counseling4LifeLLC.com or Fax: 855-357-8282. For questions, contact us at (210) 209-0642 for Counseling4Life and at (830) 800-0213 for GoodMindrx. Client Information Records for: ⬚ Individual counseling ⬚ Couples/ Family counseling* ⬚ GoodMindrx services ⬚ Group counseling* * For Couples/ Family/Group counseling requires consent from all involved. All Client(s) Name(s) ( First, Last): ______________________________________________________________________________________________ Other Names Used: Date of Birth: Age: Requestor Information Legal Name: Date of Birth: Relationship to Client: Do you have legal right to access the records? (Attach legal documentation if not the client i.e. DL and court order) ⬚ Yes ⬚ No Email: Phone: By when do you need your records to be received? Requests take 15 days to process and require proper authorization and payment. Recipient Information Name (include “and/or”) Entity: Delivery Method ⬚ Email: ⬚ Fax: ⬚ Mailing Address: . Purpose of Request: What specific information would you like included? ________________________________________________________________________________________ ________________________________________________________________________________________ Availability for Consultation:Please provide convenient times for a call within the next 3 business days. If needed, your provider may arrange a follow-up. Your preferred times: Choose one type of request (Standard or Affidavit) : ⬚ Standard Record Request: $30 per request. (check all to be included in Standard Records Request) ⬚ All Progress Notes ⬚ Only Specific Dates of Progress Notes: ⬚ Treatment Plan ⬚ Appointment History ⬚ Insurance Information and Billing Statement ⬚ Entire Record (all progress notes, diagnosis, treatment plan, attendance, insurance information, billing records) ⬚ Other (specific documents only) : ⬚ Affidavit Request: $15 per Affidavit (each Affidavit requires its own separate authorization form) ⬚ Written Summary of Treatment, Letter ⬚ Form, Report, Assessment attesting to client’s diagnosis or condition ⬚ Affidavit of Treatment Participation/Attendance ⬚ Other: Request for Mental Health Records Conditions and Fees: Below, check which service(s) you are requesting to fulfill your request. Record requests cannot be billed to insurance and payment is collected from the payment method provided in your client portal. ⬚ Paper or electronic copy-a flat fee of $30 applies for both paper and electronic copies. Electronic copies are provided by default unless the client requests otherwise. Postage applies to paper copies. ⬚ Postage is based on an estimated $15 per item will be added for mailed paper records. ⬚ Notary costs of $20 per request will be added to each request. ⬚ Affidavits (letter, treatment summary, report, assessment, form) are $15 each for executing an affidavit attesting to the client's diagnosis, condition, or treatment summary; additional fees may apply. Acknowledgement and Consent By signing, I agree to the following: Therapeutic Discretion: Records will only be released if deemed appropriate. Revocation: You may revoke consent at any time in writing, but released information cannot be retracted. Privacy: Third-party information will be redacted unless consent is provided. Electronic Risks: PHI may be vulnerable during electronic transmission. Authorization: A signed consent specifying records and recipient, along with full payment, is required. I, the client or the client’s legal representative, authorize the providers at, and/or their practice, Counseling4Life, LLC or GoodMind Rx. to disclose and receive my protected health information, including clinical and psychothera

FAQs

How long does it take to process a mental health records request?

Requests take 15 days to process when proper authorization and payment are provided.

What information does the form require from the requester?

It requires legal name, date of birth, relationship to the client, whether the requester has legal right to access records, contact details, and any needed legal documentation if not the client.

What fees apply for standard record requests and affidavit requests?

Standard record requests are $30 per request, with optional items such as postage for mailed paper records and $20 notary costs per request. Affidavit requests are $15 each and require separate authorization forms.

Sep 15, 2026

Uploaded by Rhys