Authorization for Release of Information

Untitled Document

1420 Key Highway Baltimore, MD 21230 www.drstevesobelman.com				Tel - (410) 230-7800 Tel Direct - (410) 230-7828 Fax - (410) 230-7806 steve@drstevesobelman.com
		Dr. Steven A. Sobelman, P.A.

AUTHORIZATION FOR RELEASE OF INFORMATION

This form is an agreement between you and your therapist, Dr. Steven A. Sobelman.

1. I authorize Dr. Steven A. Sobelman to (check all that apply):*
Send Mail/Email/Fax
Receive Mail/Email/Fax

2. Check all that apply:
Report of the initial evaluation/consultation
Progress notes (provide dates in comments)
Psychological assessment (provide dates in comments)
Pertinent information (explain in comments)
Engage in verbal (face-to-face/phone) communication

3. On the following patient:*

4. To the following person or organization:*

5. Comments
Please elaborate on any items that you checked (above) that need further clarification:

This authorization ends on:*
MM slash DD slash YYYY

Patient Responsibility Statement:*
By filling in my name (below) and submitting this Authorization for Release of Information form, I am attesting to the fact that I release Dr. Steven A. Sobelman from all claims and responsibilities which result from such release.

I do accept the previous statement

I do not accept the previous statement

Your Name:*
First Last

Your Email:*

Date:*
MM slash DD slash YYYY