Authorization for Release of Information

Authorization for Release of Information

This document serves as a lawful consent for the release of specific information by Healing Harmonies, LLC. The undersigned hereby agrees to the disclosure of information as outlined below.

Section 5. Consent Terms
The authorized signature below acknowledges that permission for the release of personal information as described and consent can be withdrawn at any momvent by providing a written notice to Healing Harmonies, LLC, barring any actions already taken in reliance on this consent.
This authorization expires on the date selected. If no date is selected authorization will expire upon termination of services.

MonthDayYear
Date
Please confirm your identify:*

I am the Client.I am the Parent, Legal Guardian, Personal Representative of the Client.
Name:*

First NameLast Name
Authorized Signature:*

Clear
Date:*

YearMonthDay
Date
Time:*

Hour Minutes
Should be Empty: