Authorization for the Release of Information

I authorize (name of Agency/Physician/Organization)*
to release all available information to The Center for LifeSkills and Stefanie Peck, M.A. CCC-SLP for the purpose of providing the appropriate services and continuity of care.
I also authorize The Center for LifeSkills and Stefanie Peck, M.A. CCC-SLP to release all available information to the above-named entity for the purpose of providing the appropriate services and continuity of care. This authorization remains in effect until either party notifies the other in writing that it is terminated.
Patient’s Name*
Date of Birth*
Date Format: MM slash DD slash YYYY
Signed:
Name and Relationship*
Date*
Date Format: MM slash DD slash YYYY
Enter Code: