Authorization for the Release of Medical Information

Patient

D.O.B.

Address: Street

City/State

Zip

I authorize the following release of medical information:

Name

Phone

Fax

Address

David Flume M.D.

Phone: 512-329-5575

Fax: 512-329-6141

Address: 300 Beardsley Ln. Bldg C #202 Austin, TX 78746

I understand that such disclosure will be made for the purpose of psychiatric treatment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient

Witness

Date

Your information will be encrypted.