Authorization to Release/Obtain Confidential Information

CLIENT INFORMATION
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
DOB
Address*

Street Address

Unit #

CityState

Zip Code
I hereby grant Dr. Elliott Kronenfeld permission to release/request the following information:

AUTHORIZATION
I am not giving permission for any re-disclosure of this information other than as specified above.
I understand that I may revoke this consent at any time, except to the extent that action based on it has already begun. Revocation of this consent requires written notification. In any event, I request that this authorization to release information become invalid after
days.
Having read or having had read to me and understood this form, I release Dr. Elliott Kronenfeld, LLC from any liability arising from release of this information, providing the information is released in accordance with applicable law.
Client's / Guardian's Signature*

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Date*

MonthDayYear
Date
Witness Signature

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Date

MonthDayYear
Date
Should be Empty:

AUTHORIZATION TO RELEASE/OBTAIN CONFIDENTIAL INFORMATION