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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).

Please Check:

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

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