AUTHORIZATION FOR THE RELEASE OF CONFIDENTIAL INFORMATION
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:
Phone
Fax
Provider of Health Care:
Phone
Fax
Other Authorized Individual:
For the Purposes of:
Phone
Fax
Signature *
Full Legal Name *
Date: *
MM
/
DD
/
YYYY
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.
Submit
Never submit passwords through Google Forms.
This form was created inside of lovetherapycenter.org. Report Abuse