Release of Information - Client Self-Service

1320 South Frontage Road, Suite 200  Hastings, MN  55033-2481
651-500-0905   651-437-2616 fax

Authorization for Release of Protected Health Information

Electronic Communication Consent Acknowledgment:  

Client Name:  
Client Date of Birth:
Name & Relationship of Individual Signing this Form: ,

The undersigned hereby authorizes Lutz Therapy/Tom Lutz & Associates to

The following information:

Allowable formats for the communication of this information include:

This information is to be released for the purpose of: This authorization can be revoked at any time but not retroactively to information exchanged. The individuals and organizations named above are released from legal responsibility or liability for release of the above information to the extent indicated authorized therein.

I understand that I may cancel this release at any time by notifying the provider in writing. I understand that the release will take effect on the date signed and will remain in effect for one year unless an earlier expiration date is indicated here:

Leave this empty:

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Signature Certificate
Document name: Release of Information - Client Self-Service
lock iconUnique Document ID: d57467ef9afc1066fb370d49188fdd8834cebbdd
Timestamp Audit
April 15, 2020 11:23 am CSTRelease of Information - Client Self-Service Uploaded by Anne Hewitt - IP
April 16, 2020 3:10 pm CST Document owner has handed over this document to 2020-04-16 15:10:23 -