Consent To Release Information Form

Please complete this form to authorize the release of your personal information.

Name

    Phone Number

      Email Address

        Information to be Released

        I authorize the company to release the following information:

          • Medical Records

          • Financial Records

          • Personal Identification Records

          Acknowledgment & Signature

          I understand that my consent is voluntary and that I can refuse or withdraw consent at any time. I acknowledge that once my information is released, it may no longer be protected under certain privacy laws. I confirm that I am legally authorized to provide this consent.

          Name:

          Date:

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          Thank You for Completing the Form!

          Your privacy is important to us.

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