Spencer Psychology

Authorization to Release Information

Client Name:  

I authorize the exchange of healthcare information between Spencer Psychology and:
Exchange with:  
Address:
Phone/Fax:

Relationship to Client:



 
Information to be Exchanged (Please check choice or write in details for “other”):

 

Prohibition of Redisclosure: This release does not authorize subsequent disclosure by its recipients.

Purpose of Release:

 
 

 

Authorization is valid for one year, unless otherwise instructed. I understand consent can be revoked by me at any time in writing, except to the extent that action has been taken in reliance on it by agents of Spencer Psychology.


Your Signature:  

Date: