FORM – Release of Information – Refreshing Waters Counseling

I hereby authorize Refreshing Waters Counseling to release my information to:

Released to name

Purpose

Field Group Open

Name*

Email*

Phone*

Relationship*

Field Group Close

Patient's First Name*

Patient's Last Name*

Patient Address

Patient City

Patient Zip

Patient State

Patient Phone*

Date of Birth*

MM

DD

YYYY

Field Group Open

I authorize the following information to be released from my records*

All Dates

Through

Date of service

Date of service start

Date of service end

Field Group Close

Please select the appropriate item(s)*

Please Specify

I understand that I may revoke this authorization at any time, except to the e