• COORDINATION OF CARE CONSENT FORM

  • I authorize The Center for Psychological Well-Being PLLC to release and/or obtain confidential information contained in my patient record to and from the following physician(s): (If you do not have a Primary Care Physician, click the button that says "I do not have a Primary Care Physician" and continue with the rest of the form.)

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  • Others I wish information to be disclosed to (if any):

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  • The use of this consent by The Center for Psychological Well-Being is effective for one year from the date of signature, and may be revoked by myself, in writing at any time. This consent is being signed voluntarily and under no circumstances is a precondition of treatment.

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