PLEASE NOTE: All patients over the age of 18 must complete this form themselves. If the patient is a child under 18 OR has a MPOA, a legal guardian or representive may complete this form.
Please initial each item to signify agreement and sign below. If you have any questions regarding the policies of Austin Neuropsychology, PLLC, please discuss them with the office staff or your neuropsychologist.
I grant release of information to the following individuals until such release is canceled in writing:
I understand that I have the following rights with respect to telehealth consultation: