HIPPA Form If you are human, leave this field blank.Client InformationFull Name *Date of Birth *Release of InformationRelease of Information I authorize the release of information including the diagnosis, records, examination rendered to me and claims information. This information may be released to:Name of Person & Relationship to YouName of Person & Relationship to YouName of Person & Relationship to YouInformation is not to be released to anyone *-Choose-Yes, No one is to ever get my informationOnly the People I have DesignatedIf you are unable to reach me, please:Leave a detailed messageLeave a message asking me to return your callText me requesting me to call backToday's Date *By submitting this, I am confirming that this represents my authorization and electronic signature so that everything submitted is accurate and these are my desires moving forward.-Choose-YesNoSubmit
