Authorization & Release Form - Dr. Malcolm Anderson

AUTHORIZATION AND RELEASE FORM

I, the undersigned, do hereby authorize Dr. Malcolm E. Anderson, to communicate with

Full Name *

Full name of person with whom Dr. Malcolm Anderson Ph.D. can share information with.

regarding information concerning my treatment as it pertains to

Particulars of information to be shared *

To the extent authorized herein, I therefore, waive my right of confidentiality and privacy with respect to this information and wish it to remain in confidence with, and only with, Dr. Anderson and the above mentioned party. Further release of this information without my authorized consent is considered unlawful.

I have read this document carefully and understand its contents and terms and, furthermore, agree to the authorized disclosure of information mentioned to the above mentioned parties.

Full Name of Patient *

Please note this will be accepted as a digital signature. Dr. Malcolm Anderson Ph.D. may also require a copy of this to be physically signed at the practice.

Date *