Authorization for Release of Information
Patient / Individual Authorizing the Release of Information:
Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Professional / Service Provider Disclosing Requested Information:
Name
*
First Name
Last Name
Organization
Phone Number
Email Address
example@example.com
Address
City, State
Consent
*
I hereby authorize the release (verbally and in writing) of any and all records, notes, memorandum, documentation, information, and/or prior psychological test results, pertaining to, but not limited to my medical, psychiatric, psychological, social, drug/alcohol use, academic, child protective services, and/or criminal/legal history to Bundle Therapy
*
This release also allows for an exchange of information between Bundle Therapy and the above-named professional. I further release Bundle Therapy from any and all liability that may attach as a result of the release of said information. I am aware that I may withdraw this release at any time in writing.
Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty:
