Authorization to Release – Obtain309 S. Sharon Amity Road, Suite 310Charlotte, NC 28211AUTHORIZATION TO RELEASE INFORMATIONI authorize my Wellness Counseling Center therapist to release all pertinent medical/therapeutic information to the below named therapist or practice for the purpose of my treatment. I understand that medical/therapeutic information deemed important will be shared with the below named therapist or practice and I agree in full with this consultation aimed at enhancing my current treatment. I understand this authorization may be revoked by me at any time and for any reason and must be done so in writing.My Current Therapist or Practice:(Required)New Therapist or Practice:(Required)AUTHORIZATION TO OBTAIN INFORMATIONI authorize the below named individual or provider to release all pertinent medical/therapeutic information to my Wellness Counseling Center therapist, for the purpose of my treatment. I understand that medical/therapeutic information deemed important will be shared with the below named therapist and will be used to enhance their knowledge of my past and present medical/therapeutic condition. I agree in full with this consultation aimed at enhancing my current treatment. I understand this authorization may be revoked by me at any time and for any reason and must be done so in writing.Outside party, i.e. Physician:(Required)Wellness Counseling Center Therapist:(Required) Please provide your information below:(Required) First Name Last Name Consent(Required) I agree to the above statements.By checking this Consent it acts as my electronic signature.Date(Required)
