Authorization for Release of Information
Nicole Graham, Ph.D.
Licensed Psychologist (PY#10889)
11760 W. Sample Road, Suite 103 Coral Springs, Florida 33065
Patient / Individual Authorizing the Release of Information:
Name
First Name Last Name
Birthdate
Month Day Year
Date
Email
example@example.com
Professional / Service Provider Disclosing Requested Information:
Name
First Name Last Name
Organization
Phone Number
Fax Number
Email Address
example@example.com
Address
City, State
Consent
I hereby authorize the release(verbally and in writing) of any and all records, notes, memorandum,documentation, information, and/or prior psychological test results, pertaining to, but not limited to my medical, psychiatric, psychological, social,drug/alcohol use, academic, child protective services, and/or criminal/legal history to Dr. Graham
This release also allows for an exchange of information between Dr. Graham and the above-named professional. I further release Dr. Graham from any and all liability that may attach as a result of the release of said information. I am aware that I may withdraw this release at any time in writing.
Signature
Clear
Date
Month Day Year
Date
Should be Empty: