Commonwealth of Massachusetts
Department of Mental Health
Authorization for Release of Psychotherapy Notes
Two Way
PN v. 2018 07
Page 1 of 2
1. Patient/Applicant Information
Name: ______________________________________________________________________
Other Names: ________________________________________________________________
Street: ________________________________________________ APT.#: _____________
City
/Town: ____________________________ State: ___________ Zip Code: _________
Social Security #:___________________ Date of Birth: __________________________
Phone : __________________________
2. Authorization to Release: I authorize the Department of Mental Health (DMH) to receive and
release Psychotherapy Notes, from or to the Person, Agency or Facility named below, either
verbally or in writing.
Person, Agency or Facility (e.g., name and
address of hospital, outpatient provider,
residential program, other)
Name: _____________________________
Attention: ___________________________
Street:______________________________
City/Town: __________________________
State/Zip Code: ______________________
Phone: _____________________________
Fax: _______________________________
DMH Contact Information:
Name: _____________________________
Street:______________________________
City/Town: __________________________
State/Zip Code: ______________________
Phone: _____________________________
Fax: _______________________________
Email: ______________________________
3. Dates of the psychotherapy notes you want shared: (Specify dates)
Dates of Requested Information: From: _______________ To: _______________
4. Purpose of the Release: (must check one)
Personal Use Coordinate care Referral Facilitate billing
Obtain insurance, financial or other benefits
Other purpose (please specify below):
I understand that:
• I have a right to revoke this authorization at any time.
• If I revoke this authorization, I must do so in writing and present it to DMH at the DM
H
address identified above or the DMH office in my area. (Find DMH area offices at
www.mass.gov/dmh-offices-facilities-and-staff-directory; call 1-800-221-0053; or email
dmhinfo@MassMail.State.MA.US.)
• The revocation will not apply to information that has already been released pursuant to this
authorization.
• The revocation will not apply to my insurance company when the law provides my insurer
with the right to contest a claim under my policy.
