1. Authorized Representative Details: Used when someone other than the patient is authorizing the release, including legal authority documentation

2. Specific Exclusions: Section for listing any specific information that should NOT be released, used when patient wants to restrict certain information

3. Emergency Contact Information: Optional section for providing emergency contact details, particularly useful for ongoing care situations

4. Electronic Release Authorization: Additional permissions specifically for electronic transfer of records, used when digital transmission is anticipated

5. Payment Information: Section for any applicable fees for records release, used when charges apply

1. Schedule A - Types of Mental Health Records: Detailed checklist of specific types of mental health records that can be released (e.g., psychiatric evaluations, therapy notes, medication records)

2. Schedule B - Consent Revocation Form: Form that can be used by the patient to revoke the authorization at a later date

3. Appendix 1 - Privacy Notice: Detailed information about privacy rights and how the information will be protected

4. Appendix 2 - Glossary of Terms: Definitions of medical and legal terms used in the document for patient clarity