Authorization to Disclose and Release PHI

Name*
First Last
Date Of Birth*
Date Format: MM slash DD slash YYYY
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 +

Name	Phone Number