Release of Information - Client Self-Service
1320 South Frontage Road, Suite 200 Hastings, MN 55033-2481 651-500-0905 651-437-2616 fax LutzTherapy.com
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:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Release of Information - Client Self-Service
Agree & Sign