Annual Release of Information

Annual Release of Information
Aspire Wellness Center, Inc.

5022 Campbell Boulevard, Suite L-M Nottingham, MD 21236

Phone: 443-442-1568 | Fax: 443-442-1569 | Email: contact@aspire-wellness.org
Client Name*

First NameLast Name
Who is completing this form? (Relationship to the Client)*

SelfParentGuardianLegal RepresentativeOther
Client's Preferred Name
If different from the client's legal name
Client Date of Birth*

MonthDayYear
Date
Client/Guardian Email*
example@example.com
Client/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Health Insurance Provider

Used for billing and insurance purposes ONLY
Insurance Company*
Customer Service Phone Number*
This number can be found on the back of your insurance card.Format: (000) 000-0000.
By signing below, I acknowledge that the Billing Department at Aspire Wellness Center may have to communicate with my Health Insurance Provider by providing verbal or written discussion of my case to confirm I am receiving services for a billable diagnosis.
Signature*

Thank you for completing the Annual Release of Information
By submitting this form I understand that:
- This authorization is voluntary. My treatment will not be impacted if I do not provide Emergency Contacts.
- This authorization is valid 1 year from the date signed.
- I may revoke/withdraw this authorization at any time by notifying Aspire Wellness Center in writing.
Signature*
Should be Empty:

Primary Emergency Contact