Center for Anxiety - Statement of Release

Statement of Release

Authorization to Request and/or Release Information
Client's Full Name:
Date of Birth:

Month Day Year
Date
I authorize Center for Treatment of Anxiety and Mood Disorders to request and exchange confidential professional information, including personal, psychological, medical records and opinions with:

First Name Last Name
Name of Person or Organization
Phone

Address

Address

Address

I understand that I have no obligation whatsoever to disclose the requested information and that I may revoke this consent at any time by informing the Center for Anxiety and Mood Disorders or the above named parties. In consideration of this consent, I hereby release the Center for Anxiety and Mood Disorders and the above named parties from any and all liability arising therefrom.
Signature of Patient or Legal Representative

Clear
Date

Month Day Year
Date
Print Name
Relationship to Patient
Should be Empty: