Authorization to Release Protected Healthcare Information

Authorization to Release Protected Healthcare Information

This form requests and authorizes J. Gregory Turnbull, Psy.D., J.D. and the named persons and/or entities
to disclose, release, exchange, and use my protected healthcare information.
Client Name(Required)
Date of Birth(Required)
Email(Required)
Email address to be used for confirmation copy of this document.
Scope(Required)
Consent(Required)
Hidden
MM slash DD slash YYYY
This authorization expires after one year or at any earlier time you choose by giving notice to Dr. Turnbull, 
except to the extent that action has been taken in reliance on the authorization by any of the parties listed.
This field is for validation purposes and should be left unchanged.