melodysmiththerapy.com - Release of Information Form

Release of Information Form

Melody Smith Therapy
This is a consent for release of information (hereinafter referred to as the "Release of Information") about:
Name*

First NameLast Name
Social Security Number:
Date of Birth:*

MonthDayYear
Date
I authorize, Melody Smith Therapy Group to release or obtain (select below)
Name / Organization
The following specific information:
This information may be used only for the following purposes:
The release of information is valid untill...

MonthDayYear
Date
This Release of Information is not automatically renewable. it expires automatically at the end of the period specified unless revoked in writing sooner.

I understand I have the right to see this information at any time. I understand that I can revoke this consent in writing to both the person giving and the person receiving the information. Any information already released may be used as stated on the consent. By my signature below, I affirm that I have read this release or it has been read to me, and I understand its content.
Individual's Printed Name*
Signature*

Clear
Date

MonthDayYear
Date
Witness Information
Witness Printed Name
Signature

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Date

MonthDayYear
Date
Should be Empty: