Lauren Rothstein5550 Glades Road, Suite 500Boca Raton, FL 33431Phone: (561) 962-1335
AUTHORIZATION FOR RELEASE OF MENTAL HEALTH RECORD
(Also known as Protected Health Information)
I authorize Lauren Rothstein to use or disclose information from my mental health record, which may include information about psychiatric diagnosis and treatment and substance abuse issues to:
By signing below, I acknowledge that I have read and understand this Authorization.
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