AUTHORIZATION TO RELEASE INFORMATION Client's Name * First Name Last Name Date of Birth * MM DD YYYY I hereby authorize Stephanie Johnson Therapy Services to obtain from the following * from * and to release to the following * Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country The following documents / information from the records pertaining to services received Date of Service * MM DD YYYY The documents to be released are described or listed as * The records are required for the specific purpose of * I understand that my authorization is effective one year from the date of my signature and that the information will be handled confidentially in compliance with all applicable federal laws. I understand that I may see the information that is to be sent, and that I may revoke the authorization at any time by written, dated communication. I have read and understand the nature of this release. Signature of Client / Client's Designated Representative * First Name Last Name Date * MM DD YYYY Date * MM DD YYYY Thank you! Your form has successfully been submitted. We will process it as soon as possible. If you have any questions, please contact stephaniejohnsontherapy@gmail.com or 651-354-1443.
