SFStress Release of Information

SFStress Release of Information
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Who are you seeing at San Francisco Stress & Anxiety Center?*
Name of Parent or Guardian (if client is a minor)

First NameLast Name
Please State Who This Release of Information is Purposed For.*
Address of Person This ROI is Purposed for*
*Phone Number of person this ROI is purposed for*
Please enter a valid phone number.
Fax Number of the person this ROI is purposed for
Email address of the person this ROI is purposed for
Today's Date*

MonthDayYear
Date
You are authorizing San Francisco Stress and Anxiety Center to release:

Full recordsYour name and status as a patientBilling StatementTreatment summary, including dates seen, diagnosis, and treatment planCoordinating care (scheduling and billing)Other
Please list any specific dates you are requesting records for (if there are no specific dates, please skip this)
You are authorizing San Francisco Stress and Anxiety Center to release:*

Full recordsYour name and status as a patientBilling StatementTreatment summary, including dates seen, diagnosis, and treatment plan
Signature*

Clear
I accept that this is the legal representation of my signature.

Note: Release expires 1 year after the date signed by the person served unless otherwise noted here.
Should be Empty: