Release of Information Authorization/Request forms may be obtained by your provider or at Tri-City Mental Health Services locations: 

Adult Services - 2008 N. Garey Avenue Pomona, CA 91767

Child and Family Services - 1900 Royalty Drive Suite 180 Pomona, CA 91767

All requests for mental health records require a properly completed Authorization for the Release/Disclosure of Information including subpoena requests.  Authorizations not properly completed and signed will not be processed and may delay records to be sent.  Prior to releasing information and records, releases are reviewed and approved by designated case provider.  Fees may apply.  Please contact Medical Records department for details. 

Before submitting your request, it is important to review the form for completion, including:

1. Personal identifying information of client, including full name, date of birth and Social Security Number (the last four digits are acceptable) 
2. Name, address and phone number of the individual or organization to which you want the records released 
3. What the information will be used for 
4. Description of Requested Information 
5. Time period for the information requested 
6. Initials where required
7. Signature and date