Document Request Form

The facility/provider and Alpine Academy are released from all liability that may arise from the release of information which I hereby authorize. I understand that the records may contain diagnosis, treatment, and prognosis with respect to physical or mental conditions, to include records of alcohol and drug abuse, communicable disease, history of abuse and/or treatment notes and conclusions. A photocopy of this authorization shall be effective as an original.

Release the following information (please check applicable boxes):

hereby certify that I am the requester named in the accompanying records request submitted to Alpine Academy. I understand and agree to abide by the policies and procedures governing records requests set forth by Alpine Academy.

Furthermore, I acknowledge that by signing this form, I am authorizingAlpine Academy to release the requested records to me, subject to any applicable laws, regulations, and policies.

I solemnly affirm that the information provided in the records request is true and accurate to the best of my knowledge. I understand that any falsification of information may result in the denial of my request and may subject me to legal consequences.