Insurance Information Release Authorization Form
Provide your client details and sign to authorize Inner Truth Counselling to share relevant records with your insurance company.
Client Name
*
First Name
Last Name
Date of Birth (MM-DD-YYYY)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Phone Number (Format: (000) 000-0000)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Company Name
*
Insurance Policy Number
*
Insurance Company Phone (Format: (000) 000-0000)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Consent to Release Information
*
Client Signature
*
Today's Date (MM-DD-YYYY)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Authorization
Submit Authorization
Should be Empty: