Authorization to Release/Obtain Information

I hereby authorize my clinician, of Marsh-Knickle & Associates, to release/obtain the following type(s) of information pertaining to my therapy to the following individuals and/or organizations:

Client's First Name

Middle Name

Last Name

Clinician's Name

Please use the text box below to indicate the Individual/Organization receiving the information, their Contact Information, the Types of Information being released, and the Reason for releasing the information.

Type here...

Client's or Parent/Guardian's Initials

*Please note: The client or an authorized representative, may rescind or amend the authorization in writing at any time prior to the expiration, except where action has been taken in reliance on the authorization.

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

I release forever the above-named persons and institution from all legal liability that may arise from the release of the information.

Client or Parent/Guardian's Signature:

Date:

This authorization expires on (Date):

Your information will be encrypted.