Authorization to Release Confidential Information
Restoring Hope Therapy-30 Burton Hills Blvd #575 Nashville TN 37215-(615)241-0378
Client Name
*
First Name
Last Name
Client Address
Street Address
City
State / Province
Postal / Zip Code
Client Email and Phone Number
example@example.com
I authorize Restoring Hope Therapy Services to exchange information with:
Please provide the contact information
Name of Person or Organization
*
Address
Street Address
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: