Statement of Release
Authorization to Request and/or Release Information
Client's Full Name:
Date of Birth:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit 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
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Person or Organization
Phone Number
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Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Person or Organization
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Print Name
Relationship to Patient
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