STEVE FRANKLIN, M.S.W., L.C.S.W.
6829
Gravois Ave. 314-517-8383
St.
Louis, MO 63116 FAX 203-738-4036 SteveFranklin@JUNO.com
AUTHORIZATION FOR RELEASE OF INFORMATION
Your Name: _______________________________________________SS #:____________________
Street:_______________________________________City_______________ ZIP Code___________
Organization
or Person With Whom Information Will Be Exchanged
Organization _______________________________________________________________________
Name of Individual __________________________________ Phone _____________________
Street:_______________________________City_____________State______ ZIP Code___________
o Information may be requested from the organization/individual
o Information may be provided to the organization/individual
Description of information to be exchanged.:______________________________________________
__________________________________________________________________________________
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I consent to the release of the described information. I may inspect and copy the written information that is being exchanged, and I have the right to be told what information was exchanged in spoken communication. The information will not be re-released to anyone without written authorization. I understand that this consent may be revoked at any time by written notice.
Is there a termination date for this Authorization? oYes: Date____________ o No
________________________________________ _________
Client Signature Date
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Therapist Signature Date