Therapist Authorization Release Form - Howard A Gold P C 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields at the top of the form.
3. In section 4, specify the names of the therapists and groups authorized to obtain or disclose information. Check all applicable boxes for the types of information you are allowing to be shared.
4. Fill in the details of the person or organization that will receive this information, including their name, address, phone number, and fax number.
5. Indicate your relationship to this person in the provided field.
6. Complete sections regarding your therapist's ability to communicate with third parties and testify if necessary.
7. Specify the purpose for which this authorization is granted and set an expiration date for this authorization.
8. Finally, sign and date the form at the bottom, ensuring all required fields are completed before submission.

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