Connect Plus Therapy

Consent To Release Form

Consent to Release Information - 7/2020

Authorization for use/Disclosure of Protected Health Information
  • Full Name of Parent/ Guardian
  • Name and address of recipient
  • Please name all the PHI's
  • Please choose from one of the following three

  • Please add a specified date if applicable
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY