Authorization to Release – Obtain

309 S. Sharon Amity Road, Suite 310
Charlotte, NC 28211

203 W. Main Street, Suite F3
Lexington, SC 29072

AUTHORIZATION TO RELEASE INFORMATION

I authorize my Wellness Counseling Center therapist to release all pertinent medical/therapeutic information to the below named individual or provider for the purpose of my treatment. I understand that medical/therapeutic information deemed important will be shared with the above named individual 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.


AUTHORIZATION TO OBTAIN INFORMATION

I 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 above 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.
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