Physician’s Request for Release of 
Outpatient Psychotherapy Medical Information

Requesting Individual or Entity: 
 (Name & Address) __________________________________________________

I hereby request that  _________________________________________________
 (Name of the provider of healthcare, the heath care service plan, or contractor)
furnish out-patient psychotherapy medical information concerning  
_________________________________________________
(Patient’s name)
to the Requesting Individual or Entity.
This Request includes the release of any and all information pertaining to: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

[For example... ”the patient’s diagnosis and the number of visits, including the date of each 
visit.”]

The information requested will be used for the limited purpose of: 
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

The information will be kept until ________________at which time it will either be destroyed or 
returned to you.                             (Date)

Check one: 
____ A copy of this Request was sent to the patient at the following address:  _______________________________________________________

____ A copy of this Request was NOT sent to the patient, because he/she has signed a written 
waiver of the form in a signed letter to the Requesting Individual or Entity.

Date:   ________________________
Signed: ________________________
Print Name: ________________________