Consent for Release of Health Information

Consent for Release of Health Information
I/We, First Name* Last Name* and First Name (if needed) Last Name (if needed) hereby grant authorization to Calliope Health and Keith Miller Counseling, LLC so that he/she may:
Date of Birth*
Choose One*

Disclose any and all treatment information necessary for effective coordination of care (preferred)Disclose only dates of sessions as well as information about the treatment and the nature of treatmentDisclose only dates of our sessions together
To the following organization and individual(s):*
Phone Number of intended recipient of information:*

Area CodePhone Number
Specify duration of this authorization:*

One year from today's date (preferred), orfor the time period specified below
(enter time period here if applicable)
Signature of person authorizing release of information*

Clear
Printed Name*
Signature of person authorizing release of information

Clear
Printed Name
Should be Empty: