Authorization to Release/Obtain Confidential Information

AUTHORIZATION TO RELEASE/OBTAIN CONFIDENTIAL INFORMATION
- Name
  
  First NameMiddle InitialLast Name
- Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDOB
- Address
  
  Street Address
  
  Unit #
  
  CityState
  
  Zip Code
- I hereby grant Dr. Elliott Kronenfeld permission to release/request the following information:
- Name
  
  First NameMiddle InitialLast Name
- Phone Number
  include area codeFormat: (000) 000-0000.
- Email
  example@example.com
- Address
  
  Street Address
  
  Unit #
  
  CityState
  
  Zip Code
- I am not giving permission for any re-disclosure of this information other than as specified above.
  I understand that I may revoke this consent at any time, except to the extent that action based on it has already begun. Revocation of this consent requires written notification. In any event, I request that this authorization to release information become invalid after
  days.
- Having read or having had read to me and understood this form, I release Dr. Elliott Kronenfeld, LLC from any liability arising from release of this information, providing the information is released in accordance with applicable law.
- Client's / Guardian's Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Witness Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Should be Empty: