Phone #: (954)969-9002 Fax #: (954)345-7888

Permission to Release/Obtain Records

Please complete and print out the below mentioned form before submiting it to your physician.

 

Dr. I-Net has my permission to release / obtain medical, psychological, psychiatric, educational, and other records as well as treatment summaries concerning:
From/To:
Address:
City:
State:
Zip:

 

 

It is understood that this information is to be kept confidential and is to be used only to assist in the provision of services to the individual named above.

 
  Witness Signature

 

 
  Relationship to Individual Named

 

 
  Date