Authorization for Communication Form

This form provides Mind Body Centers’ therapist and clinical staff with written permission to communicate with other individuals regarding your treatment (e.g. previous therapist, current health care providers, parent, spouse).

I, ___________ authorize Mind Body Centers' staff to communicate and/or exchange information about my case with the following parties:

Authorized Party

Please provide the details of the party who Mind Body Centers will communicate information about your case to.

Name(Required)

Relationship(Required)

Phone(Required)

Fax

Information to be Released or Exchanged (check all that apply):(Required)

Intake & History

Discharge Summary

Treatment Progress

Verbal Consultation

Diagnosis & Treatment Plan

Billing & Payment

All of the above

Other

If you selected Other, please specify:

Date(Required)

Name(Required)

First Last

Patient Electronic Signature(Required)

or Parent Signature (if patient is a minor):

This release shall be valid while under the care of Mind Body Centers or until withdrawn in writing by the patient during the course of treatment.

CAPTCHA

Authorization for Communication Form

Authorization for Communication Form

Authorized Party

Ketamine Services

Mind & Body Services

Contact info

1-855-481-9605

1-888-388-0487

2451 E Baseline Rd, Suite 300, Gilbert AZ 85234