Authorization to Release Confidential Information
Restoring Hope Therapy Services LLC
205 Powell Place #216 Brentwood TN 37027
(615) 763-3613
Client Name
First Name
Last Name
Client Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Email
example@example.com
Client Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
I authorize Restoring Hope Therapy Services to exchange information with:
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Purpose of Release
Treatment Coordination
Records Request From Previous Provider
Financial Guarantor
Emergency Contact
Other
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: