• Authorization to obtain and release confidential information for the purpose of assessment and future treatment.

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  • I {nameOf5} hereby authorize Anne Till Consulting LLC to obtain and release information regarding past and current treatment for {patientName} to and from the following people and/or organizations listed below. This information may include full health history, general and specific information regarding: nutritional, lifestyle, medical and/or psychological or social assessment/evaluation/counseling/treatment and progress notes, laboratory tests, growth charts, special evaluations/testing, diet prescriptions and provided dietary and lifestyle guidelines, school performance, social and emotional functioning, special learning problems or capabilities, educational testing, etc.

    {todaysDate}

  • I {patientName} hereby authorize Anne Till Consulting LLC to obtain and release information regarding past and current treatment for myself {patientName} to and from the following people and/or organizations listed below. This information may include full health history, general and specific information regarding: nutritional, lifestyle, medical and/or psychological or social assessment/evaluation/counseling/treatment and progress notes, laboratory tests, growth charts, special evaluations/testing, diet prescriptions and provided dietary and lifestyle guidelines, school performance, social and emotional functioning, special learning problems or capabilities, educational testing, etc.

    {todaysDate}

  • 1. Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment

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  • 2. Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment

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  • 3. Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment

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  • 4. Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment

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  • 5. Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment

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  • 6. Authorization to Obtain and Release Confidential Information for the Purpose of Assessment and Future Treatment

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