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 Name Last Name
Phone Number *

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

Street Address

Street Address Line 2

City State / Province

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

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

Number of counseling sessions Alcohol/Drug usage history Session notes Report of client progress
Method of releasing information: *

Telephone Written/Fax/Email
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- If not withdrawn, this authorization expires in (12) twelve months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 *

Month Day Year
Date
Should be Empty: