Authorization for Release of Information

Authorization for Release of Information

CONFIDENTIAL
To complete this form in Spanish, click at the top right corner of the form and choose Spanish.

Para completar este formulario en español, haga clic en la esquina superior derecha del formulario y elija español.
Clients Name

First NameMiddle NameLast Name
Is Client under age 14? All legal guardians must sign a release form.*

YesNo
Clients Address

Street Address

Street Address Line 2

CityState

Zip Code
Client's Phone Number
Client's Birth Date

MonthDayYear
I give full authorization to release confidential client information to the following:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Fax Number
Email
example@example.com
Client Signature

Sign with your mouse, stylus, or finger Clear
Parent/Guardian Name if child under age 14
Parent/Guardian Signature if child is under age 14

Sign with your mouse, stylus, or finger Clear
Parent/Guardian Name if child under age 14
Parent/Guardian Signature if child is under age 14

Sign with your mouse, stylus, or finger Clear
Should be Empty: