Authorization to Exchange Confidential Information | Anat Fein

Anat Fein, MA LMFT
21760 Stevens Creek Blvd., Suite 202
Cupertino, CA 95014
(408)-310-0800
[email protected]

Name*

Date of Birth*

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:

OR, for other (listed below).

If other, please describe:

I authorize the release of information above for the following purpose(s):*

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.*

This authorization is valid until 1 year from the date below.

Are you the:*

Your name*

Your signature*

Today's Date*