Authorization to Disclose and Release PHI

Name*

First Last

Date Of Birth*

Client ID:*

Your unique Client ID would have been given to you over the phone when you scheduled your first appointment. You should also have received it in the confirmation email for your first appointment.
It looks like Client ID: ######-####

Email*

The requested information is to be released by/to and/or mutually shared with:*

Name	Phone Number

You may enter more than one by clicking the +