HIPPA RELEASE AUTHORIZATION REVIEW FORM
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
May we leave a message?
Yes
No
If you selected YES, where may we leave a message? Select all that apply.
Home Phone
Day Phone
Cell Phone
Alternate Phone
If you selected home phone, please provide your home phone number.
Please enter a valid phone number.
If you selected day phone, please provide your day phone number.
Please enter a valid phone number.
If you selected cell phone, please provide your cell phone number.
Please enter a valid phone number.
If you selected alternate phone, please provide your alternate phone number.
Please enter a valid phone number.
List any person we make speak to regarding your care. If under 18 please list and indicate parent(s) or guardian(s). (*Note- blank equals nobody)
First and Last Name
Relationship
Contact Number
Person 1
Person 2
Person 3
Person 4
Person 5
If necessary, please list authorized person(s) to bring to appointments and their relation to the client:
First and Last Name
Relationship
Person 1
Person 2
Person 3
Person 4
Person 5
Client or Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
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Should be Empty: