Release of Information

Release of Information

 

Please enter the requested information below, using a different form submission for each provider. On the next page, you’ll have the opportunity to review the completed Release of Information form and sign it. 

Client contact information

Please include your contact information here, which will be used to populate the form on the next page.

Provider contact information

Please provide the name and any available contact details for the provider with whom you want me to be in touch.

 


07/26/2024

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. 

Sign Here