Permission to Release Private Health Information

Permission to Release Private Health Information
I hereby authorize Alba Wellness Incorporated and its’ representatives to release my personal health information.

This information will be released to:
Name of Client*

First NameLast Name
Phone Number*

Area CodePhone Number
Who can we share your information with*
Address of person/agency we will share information with*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency Email
example@example.com
Agency Fax#

Area CodePhone Number
Purpose of this disclosure:
Information to be disclosed (please check all that apply):*

Number of counseling sessionsAlcohol/Drug usage historySession notesReport of client progressOther
Method of releasing information:*

TelephoneWritten/Fax/EmailOther
I am signing under the following conditions:
- My judgment is not impaired by emotional duress or any chemicals
- I may withdraw this authorization in writing at any time
- If not withdrawn, this authorization expires in (12) twelve months
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: