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Lisa K. Willis, Ph.D., CAP Licensed Clinical Psychologist (585) 4549448CONSENT TO RELEASE INFORMATION My signature below authorizes my therapist, to communicate with my current primary care/specialist
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Your signature below authorizes the specified individual or entity to act on your behalf, allowing them to execute the necessary documents or take actions related to the subject matter at hand.
Typically, the individual or entity that is designated or empowered by the signature is required to file the necessary documents or forms.
To fill out the authorization, write your name in the designated signature line, ensuring it matches your legal name, and include the date and any required additional information.
The purpose of your signature is to provide legal consent and empower another party to act on your behalf regarding specific actions or decisions.
Generally, the information that must be reported includes your full name, the name of the authorized party, the scope of authority granted, and any relevant dates.
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