Clone of Consent for Release of Information

Consent for Release of Information
Name

First NameLast Name
Date of Birth

MonthDayYear
I, First Name* Last Name* authorize the communication of clinical information between providers at WellBeing CNY and :
Primary Care Physician
Name, phone number, and email address (important for communication).
Psychiatrist
Name, phone number, and email address (important for communication).
Therapist
Name, phone number, and email address (important for communication).
Other
Name, title, phone number, and email address (important for communication)
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: