Release of Information

Optional. Sign this only if you'd like us to share or obtain information with others.

Authorization to Release and Obtain Protected Healthcare Information

Who is filling out this form?

Husband Wife

Couple ID / Family Name

Client name

Date of birth

I hereby authorize and request Primrose Counseling LLC to release and/or obtain Protected Healthcare Information of the client named above to/from:

I hereby authorize the release of all information/records regarding mental health diagnoses and treatments, drug and alcohol treatments, pharmacological treatments, and any and all healthcare information to the persons listed above.

Date

Client signature

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