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:

Tom Lutz and Associates https://lutztherapy.com
Signature Certificate
Document name: Release of Information - Client Self-Service
Unique Document ID: d57467ef9afc1066fb370d49188fdd8834cebbdd
Timestamp Audit
April 15, 2020 11:23 am CDTRelease of Information - Client Self-Service Uploaded by Anne Hewitt - admin@lutztherapy.com IP 174.53.135.153
April 16, 2020 3:10 pm CDT Document owner justin@askdavinci.com has handed over this document to admin@lutztherapy.com 2020-04-16 15:10:23 - 174.53.135.153