Authorization for Release of Information Sandy Fox Hypnotherapy

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Authorization for Release of Information
Sandra K. Fox, CMS-CHt
Palm Beach Gardens, Florida 33410
sfox@foxhypnotherapy.com
I hereby authorize the use or disclosure of my individually identifiable health information as described below.

I understand that this authorization is voluntary and that I may revoke it at any time by submitting my revocation in writing to the entity providing the information.
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby authorize Sandra K. Fox to: ( supply name(s) below)

Exchange information with:
Exchange information name(s):
For multiple names, separate with comma
I hereby authorize Sandra K. Fox to: ( supply name(s) below)

Release information to:
Release information to name(s):
For multiple names, separate with comma
I hereby authorize Sandra K. Fox to: ( supply name(s) below)

Obtain information from:
Obtain information from name(s):
For multiple names, separate with comma
Please provide any information or questions you would like to discuss. *If this is an emergency, please dial 911.
I hereby authorize Sandra K. Fox to exchange/release/obtain information:

VerballyIn written form onlyBoth verbally and in writingType option 4
With/To/From:
Name #1

First NameLast Name
Address #1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number #1

Area CodePhone Number
Name #2

First NameLast Name
Address #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number #2

Area CodePhone Number
Description of specific information to be released, exchanged, or obtained:
The specific purpose of this release is to:
This authorization expires on:

MonthDayYear
Date
I have read and understand the following statements about my rights:

I may revoke this authorization at any time prior to its expiration date by notifying the providing organization in writing, but the revocation will not have any effect on any actions taken by the entity prior to receiving the revocation.

I may see and copy the information described on this form if I request it. I am not required to sign this form to receive hypnotherapy services.
Client Signature:

Clear
Signature Date:

MonthDayYear
Date

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