Release of Information Form

Authorization for Release of Confidential Information
Patient Name

First NameLast Name
Guardian Name (if applicable)

First NameLast Name
Patient Date of Birth

MonthDayYear
Patient or Guardian Email
example@example.com
I authorize the organization or individual(s) listed below, to release, obtain, or release and obtain the requested information to Behavioral Learning LLC.
Please select one.
Contact Name

First NameLast Name
Name of Affiliated Organization
Phone Number of Organization Contact/Individual
Email Address of Organization Contact/Individual
Address of Organization/Individual

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Delivery Method
Type of information to be released:

Other
For the following purpose:

Other
Consent
Signature
Should be Empty:

Authorization for Release of Confidential Information