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AUTHORIZATION FOR THE RELEASE OF CONFIDENTIAL INFORMATION
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To maintain a high standard and coordination of care I hereby authorize the exchange of medical and or confidential information by and between LOVE THERAPY CENTER, LLC Associates & Staff and:
Primary Care Physician:
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Phone
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Fax
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Provider of Health Care:
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Phone
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Fax
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Other Authorized Individual:
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For the Purposes of:
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Phone
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Fax
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Signature
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Full Legal Name
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Date:
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Agreement & Submission
By clicking "Submit" I acknowledge that I have read, fully understand and agree to the exchange of confidential information by and between the above mentioned people / entities.
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