Release of Information Form

Authorization for Release of Information

The PsyClinic/ Mohamed S. Ahmed, MD, PA
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Birth Date

MonthDayYear
Email
example@example.com
Last 4 SSN
I hereby AUTHORIZE The Psyclinic/ Mohamed S. Ahmed MD, PA
Release Information to the Following
Name

First NameLast Name
Organization
Phone Number
Fax Number
Email Address
Delivery Method
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Disclosure

Other
Information to be Disclosed

Other
Please select your choice
This authorization is valid until the earlier of the death of the individual: the individual reaching the age of Majority; or permission is withdrawn or the following Expiration Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Consent
Printed Name of Legally Authorized Representative
First Name Last Name
Relationship Self Parent of Minor Guardian Other
Signature of individual's legally Authorized Representative
Should be Empty:

Authorization for Release of Information