Individual(s) or Facility authorized to use or disclose the information:
Cognitive Behavior Institute: 125 Emeryville Drive, Suite 230, Cranberry Twp, PA 16066
Phone: 724-609-5002 Fax: 724-299-8964
I understand this authorization may be revoked at any time by giving verbal and/or written notice to both parties. I understand release of my records will be for the purpose states on this form. Only those items checked off or listed will be released. A photocopy of this authorization shall constitute a valid authorization. I understand that once my records have been released to the party I choose they cannot be retrieved and I hereby release both parties listed above from all liability which may arise as a result of this authorization.