Tory D. Pepper, Ph.D., | A Professional Psychology Corporation Authorization for Release of Confidentially Authorization for Release of Confidentially I hereby authorize Tory Pepper, Ph.D. and: Name To engage in mutual exchange of records and/or information pertaining to: Description: I understand that the medical records and information to be released may contain information pertaining to psychiatric-related treatment, and may contain confidentially related information. I acknowledge that I have been advised of what information will be disclosed and understand the benefits and disadvantages of such disclosure. This consent form is freely given and I have not been threatened with discontinuance or refusal of services if I do not sign this form. Limitations to this release are: (Initial one) I limit this release to these subjects: Limitations: I place no limits on this release. I understand that the above named parties may FAX my Medical Records in order to help assure prompt treatment or continued care. This release shall be valid: (Initial one) Until a Specified Date Specified Date Until I notify you otherwise in writing I understand that this authorization, except for action already taken using this authorization, may be revoked by me at any time. Signature of individual Today’s Date Signature of person authorized on client behalf Today’s Date Relationship of authorized person signing for client A photocopy of this original is to be treated as an individual Tory D. Pepper, Ph.D.,A Professional Psychology Corporation Submit If you are human, leave this field blank.
