Release of Information

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Client Full Name

I authorize the exchange of my protected health information as described above. I understand this authorization is voluntary and the information to be disclosed is protected by law. I acknowledge that I can withdraw consent for release of information at any time in writing to Mindful Healing LLC.

By typing and submitting this form, you agree that your intention is to provide a legally binding signature.
By typing and submitting this form, you agree that your intention is to provide a legally binding signature.

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