Release of Information

Release of Information Form

First Name

Last Name

Date of Birth:

I hereby authorize Healing Harmonies, LLC to (check one):

Obtain records

Release information

Obtain records from:

Release information to:

Date(s) of Service:

Specific Documents/Records to Include:

Reason for Release/Obtainment:

I understand that my authorization will remain effective from the date of my signature until one year after the signed date or until services by either party are terminated and that the information will be handled confidentially in compliance with all applicable federal laws. I understand that I may see the information that is to be sent, and that I may revoke the authorization at any time by written, dated communication. I have read and understand the nature of this release. Signature required below:

Date: