Consent for Release of Information

Consent for Release of Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
I, First Name* Last Name* authorize the communication of clinical information between providers at WellBeing CNY and :
Primary Care Physician
Name, phone number, and email address (important for communication).
Psychiatrist
Name, phone number, and email address (important for communication).
Therapist
Name, phone number, and email address (important for communication).
Other
Name, title, phone number, and email address (important for communication)
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: