• I give special permission to share the following information (Please initial):

  • Approximate Dates of Service:

  • This authorization can be cancelled at any time by request, in writing, but the cancellation will not affect any disclosures already made prior to receipt of cancellation notice. This office cannot control how the protected health information will be used by the agency/person who receives it under this authorization.
  • Other Specified Expiration Date:
  • Parent of Guardian Signature: