Sage Nutrition | Release of Information
The team at Sage Nutrition, LLC appreciates the opportunity to offer collaborative care. If you are working with a therapist/counselor, physician/PA/NP, psychiatrist, or other treatment team members, this serves as a release for the Sage Nutrition team to collaborate with the individuals/entities indicated below for the following purposes:
- sending clinical records
- two-way communication between providers
- vitals review
- planning appropriate treatment program or follow-up care
- case review
- updating files

The client can choose to revoke this consent at any time by providing written notice, and after two years this consent will automatically expire. Listed above is the information that will be given, its purpose, and who will receive the information. I understand and agree with the Release of Health Information Consent Form.
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Therapist/Counselor Name and Contact Information
Medical Provider Name and Contact Information
Psychiatric Provider Name and Contact Information
Other Provider Name and Contact Information
Release of Information Completed By *
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