Release of Information I authorize Insights Wellness Center, LLC and the person or organization identified below to exchange information for the purpose of coordinating care, treatment, consultation, or another purpose identified in this authorization. Client Name(Required) First Last Date(Required) MM slash DD slash YYYY Email(Required) Person/Provider/Organization Authorized to Release Information(Required)Email(Required) Phone(Required)(123)456-7890Purpose of Communication(Required) Coordination of Care Consultation School-related Communication Insurance/Billing Other Check all that applyInformation Authorized for Release(Required) Treatment Information Diagnosis Medication/medical information relevant to treatment Other Check all that apply I understand that this authorization is voluntary. I may revoke it in writing at any time, except to the extent that information has already been disclosed in reliance on this authorization. Unless revoked earlier, this authorization will expire one year from the date signed. Consent(Required) I agree.By checking this box, I authorize Insights Wellness Center, LLC to communicate with and exchange the information selected above with the person or organization identified on this form.Electronic Signature(Required)Date(Required) MM slash DD slash YYYY
