Authorization for Disclosure of Information
  • Authorization for Disclosure of Information – Mental Health Records

    Please complete this form to authorize the disclosure of mental health information from El Consultorio PLLC. Please read carefully and ensure all data is correct before signing.
  • 14901 E Hampden Ave. Suite 390. Aurora, CO 80014

    Phone: 720-260-4115

    Fax: 720-836-6394

    info@el-consultorio.com

    www.el-consultorio.com

  • Patient Information

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  • Contact Information of Patient or Guardian

  • Format: (000) 000-0000.
  • Information Recipient Details

    This section allows you to indicate who is authorized to receive and/or share your information. Please provide the name and contact details of any individual or organization with whom you give permission for information to be shared or from whom information may be received.
  • Format: (000) 000-0000.
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  • Consent and Acknowledgments

  • Clear
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  • Should be Empty: