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Release of Information
I hereby authorize the mutual release and/or exchange of information as indicated below, in order for my clinician and clinic staff to appropriately communicate with other providers for coordination of care.
Email address
Name:
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To/From: Light on Anxiety Treatment Center
To/From: Provider Name, Email Address and/or Phone Number
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To/From: Provider Name, Email Address and/or Phone Number
Your answer
To/From: Provider Name, Email Address and/or Phone Number
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Patient or Parent/Guardian Signature
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A photocopy of this authorization is as authentic as the original signed statement of release. An original will be retained in the medical records.
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This form was created inside of Light on Anxiety. Report Abuse - Terms of Service - Additional Terms