AUTHORIZATION FOR RELEASE/REQUEST OF Information/Records

Better Life Therapy LLC

678-882-7924 175 Langley Drive Bld.A Ste2 Lawrenceville, GA 30046
AUTHORIZATION FOR RELEASE/REQUEST OF Information/Records
Name

First NameLast Name
Date of Birth
I hereby give my permission to Better Life Therapy to release or request from a third party information contained in my medical record. I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, sexual abuse treatment, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions, and that under law these records are classified as privileged and confidential and cannot be released to me or those designated by me or my legal guardian without an expressed and informed consent.

In addition, I understand that those records will not be released to entities other than those designated by myself or my personal representative or otherwise provided in federal law. This information will be released/requested upon request to the following:
To/From: (Name of agency or representative)
First and last name, address if applicable
Phone Number of agency or representative:
Please enter a valid phone number.Format: (000) 000-0000.
To Be Released * from Better Life Therapy
The type of information to be disclosed/requested is as follows:

Other
Signed this date* Day of month* year* atTime*
Signature of Client or Legal Guardian
Should be Empty: