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Ma x Psych HIA try 1 0 1 1 W. Will IA m s Sure e t, Suit e 1 0 6, Ape x, N C, 2 7 5 0 2 Phone :(9 1 9) 3 8 6 0 4 0 2; Fa x :(9 1 9) 8 8 2 0 9 3 1AUTHORIZATION TO DISCLOSE HEALTH INFORMATION Client

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PSA Total and S refers to specific tax forms used for reporting financial information related to personal income and business activities in a given tax year.

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