11/03/2024
I, , hereby give permission for the interchange of any pertinent information regarding my care and wellbeing between () and Rachel Zamore (“Rachel”), of InnerWell LLC, and request that Rachel contacts this provider in service of our work together. This provider can be reached at .
I authorize and agree to pay for charges by InnerWell LLC for Rachel’s time spent in consultation or document review related to this information exchange, and understand that these charges will be invoiced to me on a prorated hourly basis in quarter-hour increments.
This authorization is considered valid for two years from the date of signing, and may be revoked at any time with a request sent to rachel@innerwell.org.