IBSL Release of Information

Authorization for Release of Information
Michael P. Brannon, Psy.D.
Licensed Psychologist
11760 W. Sample Road, Suite 103 Coral Springs, Florida 33065
Patient / Individual Authorizing the Release of Information:
Name
First NameLast Name
Birthdate
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Professional / Service Provider Disclosing Requested Information:
Name
First NameLast Name
Organization
Phone Number
Fax Number
Email Address
example@example.com
Address
City
Consent
1
2
Signature
Clear
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: