Authorization of Information Exchange for Lori Conroy LMFT

Authorization to Exchange Information

Lori Conroy, LMFT (CA Lic. #47658) Phone: 415-328-6423
Dear Client:

This form has been created to protect your rights to confidentiality. It specifies what Designated Information about you may be recevied from, disclosed to, or exchanged with an Authorized Third Party, and the Purpose of that information.

All blanks must be filled in, then sign the form and click on Submit.

If you have any questions please contact me at 415-328-6423.

By signing this form below you agree to the following:

I authorize Lori Conroy, LMFT to disclose, receive or exchange the Designated Information with the Authorized Third Party for the Purpose specified below.

This Authorization expires one year from the date shown. However, I understand that I have the right to cancel or modify this Authorization at any time in writing via email sent to Lori Conroy (Lori@LoriConroy.com).

I understand that I have a right to receive a copy of this Authorization.

Lori Conroy, LMFT will not release to any other 3rd party any of the Desigated Information without prior written permission.
Your Full Legal Name*
Your Email Address*
example@example.com
Authorized Third Party (full name and title if applicable): *
Please chose one of the following Disclosure options*

I authorize Lori Conroy, LMFT to Disclose (send) the Designated Information to the Authorized Third PartyI authorize Lori Conroy to Receive the Designated Information from the Authorized Third PartyI authorize Lori Conroy to exchange (send and receive) the Designated Information with the Authorized Third Party
Designated Information (including any limits)*
Enter "Unlimited' if there are no restraints on the Information to be exchanged.:
Purpose*
For example: "To aid in my therapy with Lori"
Today's Date*

MonthDayYear
Date
Your Signature*

Clear
Use your mouse or touch screen to sign
Should be Empty:

Authorization to Exchange Information