After completing both forms (Patient Information & Release of Information) are completed, please send to our staff by clicking on the SEND buttons below
This authorizes the release or ability to obtain protected health information concerning the above named client.Health information may relate to my past, present or future physical or mental health condition, and the provision of my health
care, or payment for my health care services. This information may be disclosed to or obtained from the following:
I authorize ALL Health information to be disclosed OR only the following information is/are authorized for disclosure (check all to be released).
A copy of this release shall be valid as the original. THIS CONSENT EXPIRES I YEAR FROM THE DATE SIGNED UNLESS OTHERWI SE SPECIFIED.