Authorization for Release of Medical Records

I (client), DOB:
Here hereby give permission to
(therapist) of
Inner Light Counseling and Holistic Center,
285 East Main St, Somerville, NJ, 08876
to release information to and receive information
from (name or organization)
Address
Phone
Fax
Email

For the purpose of

Description of information to be disclosed:

This authorization shall remain in effect until 6 months from the date of cessation of treatment, unless revoked in writing at an earlier date.
Please see our Notice of Privacy Practices for more information on how your Protected Health Information is used and kept confidential by Inner Light Counseling.

Client Signature Date
Parent/Guardian Signature

Date