Document Request and ROI

Document Request

Please complete this form if you need your therapist to communicate with a third party or complete a form or document regarding your care. Please note, if you are requesting a document to be completed that is not a standard letter or form we complete, there is a $40.00 fee. If you are requesting a copy of your records to be printed or faxed, there is a $50.00 fee.
Name*

First NameLast Name
Email*
example@example.com
Who is your therapist?*

Asia RodriquezAlex Earley
Date of Request*

MonthDayYear
Date
Due Date of Form

MonthDayYear
Standard turnaround time is 5-7 business days.
Please indicate what you're requesting*

Confirmation of Treatment/Diagnosis LetterDisability Forms (i.e. Short Term Disability)CVCF forms/lettersCopy of recordsTherapist to communicate with another providerAccommodations request letterOther
Please upload the form(s) or document(s) you need signed or completed by your provider.

Cancelof
Do you want this document sent directly to the third party? (Note: We always send a copy to you as well)*

Yes, send via faxYes, send via emailYes, send via mailNo, please only send to me
Please indicate the purpose/use of the records.*

AUTHORIZATION TO RELEASE/EXCHANGE CONFIDENTIAL INFORMATION
This is a consent for release of information for
Client Name*
Client Date of Birth*

MonthDayYear
Date
Client Address*
Client Phone Number*
I authorize*

To release to:To obtain from:To exchange with:
Zola Counseling Solutions, PLLC
8730 Georgia Avenue, Suite 200A,
Silver Spring, MD 20910
Name of Person*
Who are we addressing the document to.
Company/Agency*
Company Address*
Company Phone*
Company Fax
Company Email
example@example.com
The following information pertaining to*

Treatment summaryDiagnosisDates of treatment attendanceOther
For the purpose of:*

Evaluation/assessment and/or coordinating treatment effortsOther
I understand that I can revoke this consent in writing to both the person giving and receiving the information. Any information released may be used only as stated on this authorization. I understand the requested and provided information will be used in support of my treatment. This consent will automatically expire one year after the date of my signature as it appears below, or on the date that I request it be revoked in writing. I understand that I have the right to refuse to sign this form and that I may revoke my consent at any time.
Printed Name of Client*
Signature of Client*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Enter coupon

Document Request