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Release of Info
Authorization for Release and Exchange of Health Information
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* Indicates required question
Client Name (First & Last Name)
*
Your answer
Name of Therapist
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Client Address
*
Your answer
Authorizes
*
Innovative Counseling Inc, 1499 Sixth Street, Green Bay WI 54304
to release
confidential health information to,
receive from
, and/or
keep in file for verbal contact
*Please un-check an option you do NOT authorize.
Release To
Receive From
File for Verbal Contact
N/A (not applicable)
Name of Designee
*
Name of the Health Provider/Person/Probation/Attorney/Other sending or receiving information
Your answer
Designee Address
*
What is their address?
Your answer
Designee Phone Number
*
Your answer
Designee Fax Number
Your answer
I authorize the above named agencies/individuals to communicate and exchange written and/or verbal information regarding treatment. I release the above named agencies/individuals from all legal responsibilities that may arise from this act. A uniform charge for reproduction may be assessed.
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