LifeLens Psychological & Counseling Services
Authorization For Release Of Information
PATIENT INFORMATION
First Name
(middle)
Last Name
DOB:
RECIPIENT
I hereby authorize LifeLens Psychological And Counseling Services, PLLC to release
my child's records to the following:
my records to the following:
verbal communication with clinician / clinic representative
Other
ENTITY TO RECEIVE RECORDS:
Recipient's Name:
Relationship To Patient
Recipient's Phone Number
Receipient's Fax Number
Recipient's Email Address
Address:
City/State/Zip
Adult Patient Signature
date
/
Month
/
Day
Year
Date
If Patient Is A Minor: Name of Parent/Guardian
If Patient Is A Minor: Parent/Guardian Signature
Date
-
Month
-
Day
Year
Date
relationship
LifeLens
Psychological &
Counseling Services
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