Fillable Please release health care information to

Authorization to Disclose Health Care Information Client name: Date of birth: Please release health care information to: Name and Organization: Address: City, State: Zip Code: Phone: By signing this Authorization, I authorize Counseling for Life, Inc. to disclose the following health information: All Health Information about me, including my clinical records, created or received by Counseling for Life, Inc. This...
Fill & Sign Online, Print, Email, Fax, or Download
Fill Online
  • Fill Online
  • eSign
  • eFax
  • Email
  • Add Annotation
  • Share
Fill Online
Rate This Form