Client Release of Information Form

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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).

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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