Authorization to Exchange Confidential Information

Anat Fein, MA LMFT
21760 Stevens Creek Blvd., Suite 202
Cupertino, CA 95014
(408)-310-0800
[email protected]
Name*
Date of Birth*
MM slash DD slash YYYY
I hereby authorize Anat Fein, LMFT, Lic #MFC 47240, to exchange confidential information with the follow person:
Name*
Function*
Phone Number*
This authorization permits the exchange of any information deemed necessary for my care, OR:
- Diagnosis
- Treatment considerations
- Treatment Plan
- Progress to Date
- Clinical Test Results
- Dates of Treatment
- Patient Records
- Summary of Treatment
- Recommendations
OR, for other (listed below).
If other, please describe:
I authorize the release of information above for the following purpose(s):*
- Cooperation between my care providers
- Verification of compliance with the requirements of my probation officer
- Verification of compliance with the requirements of my court order
- Verification of compliance with the requirements of my employer
- Other
If other, please describe:*
I understand that I have a right to receive a copy of this authorization, and that any cancellation or modification must be in writing.*
- I understand
This authorization is valid until 1 year from the date below.
Are you the:*
- patient
- patient's parent
- patient's representative
Your name*
Your signature*
Today's Date*
MM slash DD slash YYYY