Client Release of Information | Bridgepath Inc.

Client Release of Information Form

** Please fill out all fields below. If the form is incomplete upon submission, a red outline will highlight the field(s) that need to be addressed. Please allow a few moments for the submission to process before exiting the window.

This form, when completed and signed by you, authorizes your health care provider to release protected health information from your clinical record and discuss your care with the person(s) you designate and vice versa.

I hereby authorize my care provider to release/receive information and consult as pertinent to my care with the following person(s).

By checking this box I understand that my healthcare cannot re-disclose information received from another provider if that health care provider requested that the information not be re-disclosed. I also understand that I may withdraw this request at any time.

Please Check:

Bridgepath of the Upstate 104 N Daniel Morgan Ave. Suite 103 Spartanburg, SC 29306

Arbor on the Green 8037 Corporate Center Drive, Suite 400 Charlotte, North Carolina 28226

By signing my name in the box below, I authenticate that I have read, understand and agree to the terms of the Professional Disclosure Statement and Privacy Policy