Authorization to Release Information

Authorization to Release Information

Moving Forward, PLC — Michele T. Cole, Ph.D., LCSW, 117 S. St. Asaph St., Alexandria, VA 22314, 571-483-0306
Patient's Name*

First NameLast Name
Legal Guardian (if under 18)

First NameLast Name
Which therapist will you be seeing?*
I hereby knowingly and voluntarily authorize Moving Forward,PLC to exchange treatment information with the following person(s).
Name*

First NameLast Name
Organization's Name
Relationship to Patient*
Specify "other"*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Effective Date of Authorization*

MonthDayYear
Date
I understand that I must deliver written revocation to Moving Forward, PLC at 117 S. St. Asaph St., Alexandria, VA 22314, if I no longer authorize this release of information.

I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by privacy regulations.

This authorization expires one month after the final date oftreatment at Moving Forward, PLC.
Printed Name*

First NameLast Name
Relationship to Patient
Date*

MonthDayYear
Date
Signature*

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I hereby knowingly and voluntarily authorize Moving Forward,PLC to exchange treatment information with the following person(s).