Release of Information Consent Form

Patient Name

I, the patient or legal representative of the patient, hereby authorize Dr. Nancy Shosid to disclose records and/or exchange information concerning myself or the patient to the following parties:

School

Medical Doctor

Therapist

Other

None of the Above

School Name, Contact Person and Phone Number

Medical Doctor Name, Contact Person and Phone Number

Therapist Name, Contact Person and Phone Number

Other Party Name, Contact Person and Phone Number

Patient or Legal Representative Electronic Signature

Date of Signature

YYYY

Relationship of Legal Representative

This consent may be revoked by client in writing at any time.

Patient Date of Birth

YYYY